Author(s)

Solís-Cuñado S. (1), Sánchez-Cerviño A.C. (2), Martínez-Núñez M.E. (1), Gómez-Bermejo M. (1), Martín-Zaragoza L. (1), Rubio-Ruiz L. (1), Onteniente-González A. (1), Molina-García T. (1)
1. Hospital Pharmacy Service, Getafe University Hospital, Getafe (Madrid), Spain.
2. Hospital Pharmacy Service, Puerta de Hierro University Hospital, Majadahonda (Madrid), Spain.

Why was it done?

The implementation of multidisciplinary antimicrobial stewardship teams(AST) in hospitals optimizes antibiotic use in order to improve clinical results, reduce antibiotic toxicity and minimize the emergence and spread of multidrug resistant(MDR) bacteria.
The objective is to present targeted interventions for the improvement of the management of lower respiratory tract infections(LRTI) and to reflect the impact of these strategies through the presentation of antibiotic use results.

What was done?

Two main interventions have been implemented in LRTI:
-Protocolize the management of community-acquired pneumonia(CAP) in order to prioritize beta-lactam plus macrolide(bLM) combination versus fluoroquinolones(FQ) monotherapy. The aim is to decrease FQ consumption due to their safety issues and the major role of this antibiotics in the emergence of MDR bacteria.
-Identify patients with severe LRTI and/or risk factors of multi-drug resistant(RFMDR) bacterial infections to encourage nasal swab screening(NSS) for meticillin-resistance Staphylococcus aureus(MRSA) to promote de-escalation of anti-MRSA antibiotics.

How was it done?

Study period: 2023 and first semester of 2024.
-CAP guideline: we studied the bLM vs FQ consumption expressed as the ratio between bLM DOT/FQ DOT (Days Of Therapy; DOT) in all hospitalized patients. Analysis was carried out on forth-month period.
-NSS: we reviewed the total number of NSS performed and the impact on duration of antiMRSA antibiotics therapy. Analysis by semesters.

What has been achieved?

After protocolization, the BLM´s DOT/FQ´s DOT ratio increased 39.4% from the beginning of 2023 until 2024: 0.66 vs 0.92.
Our AST reviewed 378 episodes of LRTI. At least one nasal screening was performed in 60.6% of episodes (n=229/378) of which 29.2% were positive (n=67/229). The mean duration of treatment with anti-MRSA antibiotics in the positive cases was 7.42 days, while in the 214 negative cases it was 6.4 days.
69% of the patients with LRTI that have been reviewed in our AST meets at least one RFMDR.

What next?

The frequent lack of diagnostic value of respiratory samples, coupled with the high percentage of RFMDR patients, results in long-lasting broad-spectrum empirical antibiotic treatments.
It is therefore proposed that a polymerase chain reaction(PCR) test be performed on candidate patients for the purpose of screening for MRSA, with a view to obtaining rapid results that will facilitate earlier antibiotic de-escalations.

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Author(s)

Mafalda Cavalheiro 1
Maria José Rei 1
Ana Rita Silva 1
Patrícia Batalha Silva 1
Carolina Marques 1
Miriam Capoulas 1
1- Pharmacy Department, Hospital da Luz Lisboa, Portugal

Why was it done?

Low serum Infliximab are associated with lost of response and development of immunogenicity. Moreover, therapeutic levels without the control of the inflammatory activity may inform about the necessity of changing the therapeutic class. While monitoring serum levels in the absence of response is already well established, the proactive monitoring of serum levels at defined timings during the induction and maintenance phases of therapy is beginning to be recommended by several leading organizations.

What was done?

Establishment of a protocol for proactive serum monitoring of Infliximab in inflammatory bowel disease, to guide the interpretation of serum levels, optimize dosage and therapeutic response.

How was it done?

Implementation took place in several stages. 1) Theoretical and practical training culminating in the discussion and drafting of a technical guideline including a monitoring protocol with the Gastroenterology team. 2) Organization of the sample collection and analysis circuit. The analytical technique is a rapid test that allows the detection of infliximab levels and anti-infliximab antibodies. 3) Finally, dosage optimization (maintenance of the reference dosage or intensification – shortening the administration interval or increasing the dose) is carried out with the support of population pharmacokinetic models using the DoseMeRx software, interpreted in the context of the overall response assessment in conjunction with the clinical team. The main limitation identified had to do with awareness of the medical team to rational dosage adjustments based on the population model.

What has been achieved?

15 patients were included with a median age of 33 years; 11 of these were diagnosed with Ulcerative Colitis and 4 with Crohn’s Disease. A total of 24 tests were carried out (21 with a proactive strategy and three with a reactive strategy). Of the doses taken at week 6, 60% were below the reference range considered. The dosage regimen was intensified in 64% of the recommendations. Of the patients analyzed, 76% maintained their response, although the duration of treatment was less than a year in most cases.

What next?

The strategy of proactive monitoring and dose intensification may have contributed to achieving and maintaining the response to treatment with Infliximab, but the small number of patients and the duration of the analysis call for further analysis.

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Author(s)

M. López López-Cepero, H. Padilla Castaño, G. Arrufat Goterris, P. Clares Rubio, T. Bonnin Garau, A. Tugores Vázquez, C. Martorell Puigserver.

Why was it done?

A pharmaceutical care consultation (PCC) was implemented for patients waitlisted for kidney transplantation (PWKT). The PCC focuses on transplant medication education, accurate medication history, allergy review, adherence assessment and self-perception of therapeutic complexity.

What was done?

Medication non-adherence is the major issue in transplantation, and it is associated with increased risk rejection, allograft loss and patients’ death.
Medication education after the transplant was not enough. Intervening before the transplant enabled pharmacists to know the patients and develop an individualized therapeutic plan, so the patients arrive as prepared as possible on the day of the transplant.

How was it done?

PWKT were scheduled in PCC and the pharmacist review their medical history and prescriptions. Patients were contacted by telephone for an interview. A face-to-face consultation was also possible.
PCC evaluate:
1) Clinical variables: etiology of renal pathology, comorbidities, previous transplantation, current renal replacement therapy (TRR), CYP3A5 genotype.
2) Medication: allergies, current medication plan, adherence (Morisky-Green test and electronic prescription record), organization and self-perception complexity.
3) Pharmaceutical interventions (PI): deprescribe or update current treatment, reinforce adherence, propose Monitored Dosage System (MDS) or pillbox, immunosuppressants education, arrange for a second PCC, contact with their community pharmacy, send to Pharmacogenetics Committee.

What has been achieved?

The PCC was implemented in June 2024. Among the first 4 months, 28 of the 58 PWKT have been evaluated.
Analyzing the clinical variables has allowed us to describe PWKT profile. Knowing how patients manage medication, as well as the perception they have about the importance of their treatment, helps to create an action plan and better prepare the patient for the transplant.
Given that one third of the patients were non-adherent, most of the PI focused on adherence reinforce, including additional monitoring, propose MDS or pillbox pillbox and resolve medication doubts.

What next?

The next step is to include a PCC in our clinical practice and get to visit all PWKT before the transplant.
It is needed to evaluate the impacts of PCC and PI as regards clinical outcomes. Detecting improvement actions will be enriching for patients care.
The PCC can be extended to other types of solid organ transplants.

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Author(s)

Maibritt Skov Olsen, Bernd Utech

Why was it done?

Pharmacy technicians at the Medical Ward of Bornholm Hospital adjusted medication orders to align with the hospital’s medication assortment. Operating under delegated prescribing authority; they prescribed, paused, and discontinued specific medications within a framework agreement and documented changes in the Electronic Medication Module “Sundhedsplatform” system.

What was done?

Patients often bring medications outside of the hospital’s assortment. Adjustment of these medications is time-consuming and can lead to documentation challenges. Delegating this responsibility to pharmacy technicians aimed to enhance patient safety by ensuring scan-ready medications and freeing up physicians’ time for other tasks.

How was it done?

A medication adjustment list was created by the pharmacy and department physician, outlining which drugs the technicians could adjust or discontinue. Pharmacy technicians were trained, and annual audits were conducted by the department physician. In a period of 13 days, a time study was made to track interventions; consultations with physicians, and time spent adjusting medications in the Sundhedsplatform.Nurses and physicians were asked about their experience of the pharmacy technician’s work.

What has been achieved?

During the test period, 97 patients were dispensed medication, and interventions was made for 39 (40%) of those patients. Technicians performed 60 interventions, of which 11 were physician-consulted. They spent 220 minutes on adjustments and notes, saving physicians 160 minutes. Feedback from nurses and physicians was positive, with improvements in medication scanning and reduced interruptions for physicians.

What next?

The task will be expanded to include all patients in the medical and surgical wards. An extension of the pharmacy technicians’ prescribing authority is also planned.

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Author(s)

Amparo Valls-Lattur
Supervisor: Agostina Secchi

Why was it done?

Background
Introducing a pharmacist prescriber (PP) in the Community mental health services for older people (CMHSOP) to support with follow-up appointments for memory patients as a new strategy as part of the community mental health transformation (1). The aim of this Service Evaluation was to evaluate the views of patients with dementia (and/or their carers) on a pharmacist prescribing led clinic.

What was done?

After diagnosis of Alzheimer’s Dementia some patients will be started on medication to treat the disease symptoms in an effort to reduce the rate at which their cognitive abilities will deteriorate. This medication will need titrating and monitoring for compliance and side effects (2).
This new service will allow consultants to focus on diagnosis of dementia while improving waiting times for community mental health services for older people (3).

How was it done?

Methodology
The data was collected from a memory clinic within a community mental health team for older adults. Data was collected from patients’ and/or their carers’ feedback in the form of a survey. The purpose of the survey was explained to the patients and/or their carers and those who took part placed the questionnaire anonymously in a box at reception. The survey responses were collected on a weekly basis from the box, allowing patients and/or their carers to complete the survey in their own time.

What has been achieved?

Results
During the period of the survey (February until May 2024), 27 questionnaires were received. The majority (21) were completed by carer/family member, and 6 were completed by the person being treated (patient). Patients and/or their carers had to answer 10 questions using a 5-point likert scale: from strongly agree, to strongly disagree.
The majority of participants strongly agreed that the service provided was of high standard. For example:
• the majority agreed that the prescribing pharmacist was polite and considerate
• patients and their carers felt listened to and allowed them to ask questions
• their questions were answered
• everything was explained in a lay language
• they were provided with enough information about their medication
• patients and their carers or families felt involved in their care and treatment
• the majority of patients had confidence in the prescribing pharmacist
• they were given information on who to contact if they had any problems.

What next?

Conclusions
This project showed a positive impact of a new service introduced in the CMHSOP. The pharmacist prescribing role in mental health is a new service and has shown that both patients and their carers have all expressed a positive view of this new clinic. Both patients and carers found the pharmacist caring, professional and attentive to address their concerns.
Future work will look at quantifying how this new service has reduced the waiting time for these patients to be seen or followed up.

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Author(s)

Palacio-Lacambra, ME
Cabañas-Poy, MJ
Lalueza-Broto, MP
Florensa-Royo, E
Fernández-Polo, Aurora
Marrero-Álvarez, P
Juárez-Giménez, JC
Gabarro-Portella, G
Gorgas-Torner, MQ

Why was it done?

The problems caused by medication shortages are significant, pose a risk to patient care, and require good coordination between different levels of the healthcare system (primary care and hospital pharmacy services (PS)). Drug shortages can adversely affect drug therapy, compromise or delay medical procedures, and result in medication errors.

The objectives of the working group are to define the internal processes of the PS regarding the management of and communication between professionals about medication supply shortages and to coordinate the referral of primary care community patients for dispensing at the hospital.

What was done?

A multidisciplinary working group was established, including representatives from various pharmacy areas (management, outpatient dispensing, drug information center, pediatrics) and representatives from the Primary Care Medication Management Area in our Health Region, where our center serves as the reference hospital.

The “Supplier Shortage Working Instruction” has been updated, and a pathway has been established for referring patients from primary care to the outpatient pharmacies (adult and pediatric) of our hospital.

How was it done?

Internal meetings of the PS were held to update the “Supplier Shortage Working Instruction,” considering the different situations of medications in shortage (exclusive and/or non-substitutable, substitutable, and community pharmacy medications in shortage).

A meeting with Primary Care representatives was conducted to define the pathway for referring community patients with medications in shortage imported from abroad through the Spanish Agency of Medicines and Medical Devices.

What has been achieved?

The internal working instruction has been redefined, and a shared resource for the entire PS has been created to centralize relevant information for the management of medications in shortage, which is kept up-to-date.

A referral pathway has been established for Primary Care patients to the outpatient pharmacies of our hospital. Two pharmacists from the PS coordinate shortage information with Primary Care. Primary Care reports the number of patients with active prescriptions requiring medication, which ensures adequate stock levels and enables patient scheduling to enhance their experience.

What next?

Having an internal pathway has improved the management of medication shortages in the PS, as well as enabled the coordinated referral of community patients.

It is applicable to all PS involved in dispensing foreign medications due to shortages.

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Author(s)

Ina Vierø Rinder, IVR

Why was it done?

Handling medication shortages in the hospital pharmacy are time-consuming, and a lot of resources are used to find alternatives. Though shortages are a national focus in Denmark, shortages are not a priority focus in the local hospital pharmacy. Shortages are often handled “on-the-go” locally and therefore not prioritized. The hospital pharmacy uses “Medication News”, posted on internal website, to broadcast information about long-term shortages to the hospitals. The aim was to determine the occurrence of shortages among commonly used medications at Copenhagen University Hospital, Amager and Hvidovre (AHH).

What was done?

A top 100-list of most bought packages of individual chemical substances (ATC5-level) was generated. The purchase data were obtained from the hospital pharmacy at AHH for the period from October 2023 to September 2024.

How was it done?

The list was analyzed to determine how many medications had experienced shortage during the specified period. The analysis was conducted by reviewing past “Medication News”, historical e-mails regarding shortages, and the hospital pharmacy’s own record of shortages.

What has been achieved?

The top 100-list of most bought packages of individual chemical substances (ATC5-level) revealed a total of 1149 item numbers. The 500 item numbers in ATC-level V07AZ** (Chemicals and reagents for analysis) were excluded due to their use. Of the remaining 649 item numbers, 43 item numbers had experienced shortage during the specified period. Of the 43 item number shortages, 22 (51 %) had resulted in a “Medication News” on the internal website. The shortages were distributed in the ATC-levels A (16 %), B (9 %), C (5 %), D (2 %), H (9 %), J (12 %), L (5 %), M (7 %), N (30 %), R (2 %) and S (2 %).

What next?

The generated data of the top 100-list of used chemical substances has given rise to more attention on shortages in the hospital pharmacy. In the future it is assumed that the number of shortages will rise, and it should be possible to increase the attention of short-term shortages by using the obtained data e.g., integrate the data in a daily status meeting. Thereby the shortages can be handled as a priority and not “on-the-go”.

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Author(s)

Mafalda Cavalheiro 1
Joana Simões 1
Carolina Marques 1
Patrícia Batalha Silva 1
Miriam Capoulas 1
Cláudia Santos 1
1 – Pharmacy Department, Hospital da Luz Lisboa, Portugal

Why was it done?

Due to the connection with the clinical area and innovation, trials in our pharmacy services were previously assigned to each pharmacist specialized in the corresponding therapeutic area. In the beginning of 2024, the increasing number of clinical trials, coordination and investigational drug management challenges emerged and proved that the previous model was inefficient. Our aim is to develop a centralized unit that is the key to coordinate pharmaceutical activity and improve patient care in clinical trials. In addition to dispensing process, pharmacists become responsible for ensuring therapeutic reconciliation, patient education and treatment adherence, improving medication safety.

What was done?

During a time of continued growth in clinical trials number, it was defined as a pharmacy services’ goal the creation of a centralized clinical trial unit. Additionally, the need to structure a pharmaceutical consultation has arisen.

How was it done?

The process unfolded in three phases: team structuring, logistical reorganization and consolidation of the pharmaceutical care process. A lead pharmacist was appointed as coordinator, supported by a backup and three pharmacists in oncology and three in non-oncology. The major limitation was the establishment of the pharmaceutical team and their training for the several ongoing trials. The unit was reorganized into a larger area, including workstations, medication storage and a meeting room. The pharmaceutical consultation was structured into an initial evaluation and follow-ups. During the first consultation, the pharmacist conducts patient assessments, medication education, toxicity management information and drug/herbal interactions checking. Follow-up consultations focused on medication dispensing, compliance, adverse effects and patient concerns.

What has been achieved?

The centralized unit currently manages 66 clinical trials (37 oncologic; 29 non-oncologic). Seven oncologic trials regularly include pharmaceutical consultations, representing an average of 10 appointments per month. Given the benefits of pharmaceutical intervention, particularly in terms of increased adherence, reports of drug safety and compliance, the importance of this centralization is clear.

What next?

Due to logistical challenges, pharmaceutical consultations have only been implemented for oncologic oral medications. With the robustness of the centralized unit, the next goal is to expand pharmaceutical consultations to oral non-oncologic trials, following the successful model used for oncologic trials.

Author(s)

Lanzone E. (1), Baldessarelli D. (2), Tinebra A. M. (1), Albini E. M. E. (1), Panarotto A. (1), Rossi C. (1) – (1) SC Farmacia Ospedaliera ASL Novara, (2) Scuola di Specializzazione Farmacia Ospedaliera Novara.

Why was it done?

A comprehensive analysis of systemic antibiotic use in hospitals during the first half of 2024 was conducted, revealing a significant increase in the consumption of WATCH class drugs, specifically carbapenems (ATC J01DH) and fluoroquinolones (J01MA). This prompted the implementation of rigorous monitoring for prescriptions of these drug classes.

What was done?

These antibiotics are key targets of the National Plan Against Antimicrobial Resistance (PNCAR 2022-2025), which mandates a reduction of at least 10% in consumption by 2025 compared to 2022. The initiative aimed to address the rising consumption and enhance antibiotic stewardship.

How was it done?

Data were extracted from the regional IT system, with consumption expressed in Defined Daily Doses (DDD) per 100 patient days. The project monitored the use of systemic antibiotics (ATC J01), focusing on carbapenems and fluoroquinolones. Motivated requests received by the Hospital Pharmacy (FO) were reviewed for therapeutic indications, dosage, treatment duration, and the availability of an antibiogram. All requests were recorded in an Excel sheet for effective data analysis and management.

What has been achieved?

In the first half of 2024, the Hospital Pharmacy received a total of 277 motivated requests for antibiotic prescriptions. Among these, 177 requests were aligned with the objectives of the PNCAR. Specifically, there were 54 requests for fluoroquinolones, including 35 for ciprofloxacin and 19 for levofloxacin. Within this subset, 16 requests included an antibiogram, while 27 were based on empirical data. Additionally, there were 6 requests for surgical prophylaxis, 1 for continuation of therapy, 1 accompanied by a positive urine culture, and 3 that were incorrectly filled out.
The analysis of requests also highlighted a significant number related to carbapenems, with a total of 123 submissions. Of these, 120 were for meropenem, 2 for imipenem in combination with cilastatin, and 1 for ertapenem. Notably, 80 of these requests included an antibiogram, with 74 deemed appropriate based on the established criteria.

What next?

Based on the collected data, modifications to the personalized motivated request form were proposed, introducing stricter criteria for empirical use of these antibiotics. This aims to limit their use to serious and well-defined cases, representing a significant step toward more effective antibiotic therapy and improved clinical outcomes while reducing the risk of resistance. The new form specifies that ciprofloxacin and levofloxacin requests can only be made under certain conditions, and carbapenems are restricted to cases of hemodynamic instability or severe respiratory failure.

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Author(s)

Elisa Vitale, Quentin Perrier, Arnaud Tanty, Claire Chapuis, Armance Grevy, Agathe Landoas, Dorothée Lombardo, Prudence Gibert, Lénaik Doyen, Benoit Allenet, Pierrick Bedouch, Sébastien Chanoine

Why was it done?

In France, during their 5th year of study, pharmacy students complete a six-month full-time equivalent internship in a hospital setting. At our hospital, most students spend six months in a care unit to perform pharmaceutical care and promote quality use of medicines. These missions are carried out in collaboration with all healthcare professionals, either under the direct supervision of a pharmacy resident, senior pharmacist, or independently. While tasks assigned to pharmacy students in the care unit with direct pharmaceutical supervision were well known, other students reported difficulties in understanding what was expected of them, as well as a lack of confidence when integrating an established interprofessional team.

What was done?

The aim was to create and evaluate a specific training session for all pharmacy students joining a care unit for the first time.

How was it done?

Four hospital pharmacists collaborated to define the learning objectives and select the appropriate teaching tools. A pre- and post-training self-assessment questionnaire consisting of seven questions was created to evaluate students’ self-efficacy regarding the learning objectives and their satisfaction with the training.

What has been achieved?

A four-hour training session, divided into five sequences, was created. The objectives were: 1) Highlighting the challenges of joining an interprofessional team, 2) identifying the tasks and learning opportunities for pharmacy students, 3) simulating a medication reconciliation, 4) managing pharmaceutical issues through problem-solving exercises.
Regarding the evaluation, students reported that they: a) were more enthusiastic about the idea of working in a care unit after the training course (85% vs. 74%, p=0.001); b) had a clear understanding of their mission (84% vs. 53%, p<0.001); c) felt more confident in performing a medication reconciliation (93% vs. 35%, p<0.001); d) were more aware of the pharmaceutical resources available to them (95% vs. 27%, p<0.001); e) had a better understanding of how hospital pharmacy is organized (58% vs. 19%, p<0.001). Additionally, 99% found the training useful, and 94% felt that the training methods aligned with the training objectives.

What next?

Assess the long-term impact of the training and its effectiveness in ensuring that pharmacy students perform pharmaceutical care successfully and confidently