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Implementation of a screening circuit and prevention of infections in cancer patients treated with immune checkpoint inhibitors

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European Statement

Clinical Pharmacy Services

Author(s)

Alba Manzaneque, Carla Jurado , Cristina Alonso , Mireia Cairó, Glòria Molas, Fernando Salazar , Lucía Boix, Roser Font, Laura López, Jordi Nicolás, Marc Campayo, Esther Calbo

Why was it done?

Although an intrinsic risk of infection has not been associated with ICI, there are different studies and case-series in the literature in which an increased risk of infection is observed, mainly associated with the use of immunosuppressive drugs (like corticoids) for immune-mediated toxicities. The objective of implementing this circuit in our centre is to reduce all preventable infections, by carrying out an initial infection screening that allows detection of those patients susceptible to vaccination measures, prophylaxis, or specific recommendations.

What was done?

Implementation of an infection screening circuit in cancer patients treated with immune checkpoint inhibitor drugs (ICI).

How was it done?

To carry it out, a multidisciplinary work team was created (pharmacy/oncology/infections department) that designed the ICI template and the clinical circuits. At this point, we believed it was necessary to centralise requests, results, and follow-ups in the oncology pharmacy team (OPT) in order to ensure that all patients were included.
Before the patient initiates treatment with ICIs, the OPT makes the request for a pre-established ICI analysis and the oncology nurse (ON) extracts it. Within 7-10 days, the infection department checks the results and makes the necessary recommendations (vaccination/prophylaxis/specific recommendations).
The OPT is then responsible for both vaccination and initiation of prophylaxis.

What has been achieved?

A total of 30 patients (January to September 2022) have been included in the circuit, 25/30 being men and with a mean age of 67.8 (± 8.8) years.
In 25/30 the treatment was with palliative intent, and 21/30 had lung neoplasia.
The ICIs prescribed were: pembrolizumab (15/30) and nivolumab/atezolizumab/durvalumab (5/30 in each case).
Screening results are available for 26/30 patients. Some type of recommendation was made in 25/26 patients, being: 20/26 hepatitis B vaccination, 5/26 start prophylaxis (2/5 hepatitis B and 3/5 tuberculosis), 6/26 hygienic-dietary measures (aimed at toxoplasmosis).
Additionally, all previously unvaccinated patients (23/26) have been vaccinated against pneumococcus.

What next?

A comparative analysis of infection with a historical cohort is planned when larger sample size is available, to demonstrate that these types of measures reduce the occurrence of infections. Centralising this type of initiative from the OPT is key to our integration into clinical teams, by avoiding important adverse reactions and taking care of our patients.

Optimising anticoagulation counselling using video media

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European Statement

Clinical Pharmacy Services

Author(s)

Suzanne Al-Rawi, Sadeer Fhadil, Sotiris Antoniou, Rodnie Oro, Paul Wright

Why was it done?

It is suggested that 40-80% of information provided by healthcare professionals is forgotten immediately by patients (1). The trust has a checklist of counselling requirements for anticoagulants, completed in consultations with patients before discharge. Recognising the complexity of anticoagulation counselling and its time constraints, we sought to assess the use of pre-recorded counselling videos for use at ward level and as a resource for patients to refer to post discharge.

What was done?

We sought to develop anticoagulation counselling videos for ward use, with hyperlinks for patient access post-discharge. We aimed to improve information provided to patients and optimise pharmacists’ time undertaking counselling.

How was it done?

Using a patient focused questionnaire, feedback was sought on patient satisfaction as well as time totality following anticoagulation counselling. A series of short and digestible video clips (1-2minutes each) that reflected the trust checklist were recorded. The videos were played to the patient and then a follow-up face-to-face consultation was undertaken to answer any questions. Patient satisfaction and time taken was assessed through the use of the questionnaires and compared to consultations without the pre-recorded clips.

What has been achieved?

Over 4 weeks, 121 patients received anticoagulation counselling. 77 patients were counselled using videos and compared to 45 patients counselled without videos. There was a 70% reduction in time spent; an average face-to-face counselling required 24 minutes, compared to only 7 minutes if the patient had seen the videos. There was an overall increase in patient satisfaction with use of videos to 86% from 70%.

What next?

We have shown optimisation of the anticoagulation counselling process through the use of pre-recorded videos. Time spent counselling has been significantly reduced and feedback from pharmacy staff has suggested more patient-centric counselling is achieved. It has allowed for information to be standardised, with an increase in patient satisfaction and understanding. Patients have access to the videos on discharge to improve patient safety. There have not been any reported incidences since switching methods. There has been a reduction in patient queries related to anticoagulation post- discharge. Areas for further development include dubbing of the videos to several languages to improve access to all.

App PharmaClick

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European Statement

Clinical Pharmacy Services

Author(s)

Catarina da Luz Oliveira, Maria Augusto, Carla Ferrer

Why was it done?

Ideally, clinical pharmacy should be performed continually and not only at the Pharmaceutical Consultation. The usage of technologies as new communications channels between patients and pharmacists would contribute to this notion of continuous clinical pharmacy, so we started to develop the app PharmaClick. With this app, the pharmacist will be able to remotely monitor the patient therapy, to mitigate medication errors, to control adverse drug reactions, to detect possible drug interactions, and to promote therapy adherence.

What was done?

We are developing a web application called PharmaClick. This app will allow the patient, after the respective Pharmaceutical Consultation at the hospital outpatient clinic, to communicate on time with his pharmacist and to give access to several features related with his medication.

How was it done?

The app PharmaClick is being developed using open source technology, Ruby on Rails, and is currently in a small-scale implementation to prove the viability of the project.

What has been achieved?

The PharmaClick app is now a pilot project and is being used as support on the Pharmaceutical Consultation. The patient is invited to download the app PharmaClick and he is introduced to its features, such as:
• How to identify his medication and dosage;
• How to set alarms for taking the medication and making the respective register, allowing the pharmacist to check the therapy adherence rate;
• How to request the scheduling of a new pharmaceutical appointment;
• How to communicate with the pharmacist using the chat to clarify some doubts that he may have after the appointment;
• How to register possible adverse drug reactions;
• How to submit the quality of life form, which will allow to indirectly measure the therapy efficiency.

What next?

The project is sustainable since it is easily applied on other health institutions. The app allows to anticipate possible medication problems. The goal is to provide health solutions that are remote and effective, to improve the patient participation in the healing process and in his wellbeing in the long run. The treatment success is easily improved at the distance of a PharmaClick.

Implementation of medication sessions in a post-stroke therapeutic education programme

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Clinical Pharmacy Services

Author(s)

Florian Poncelet, Cedric Mwamba, Valentine Foulon , Anne-sophie Da Silva Rego, Catherine Floret

Why was it done?

Medication adherence of post-stroke treatments is important in preventing stroke recurrence. Problems of adherence with these medications are frequently encountered. Patient education is therefore essential in the management of this pathology.

What was done?

The creation of tools for the medication session of the post-stroke therapeutic education programme and the measure of the activity impact on patients’ knowledge of their treatments.

How was it done?

The session is led by a pharmacist in the form of a Game of the Goose, with the cards divided into 3 different colours, each corresponding to one of the 3 categories seen during the activity: General Questions, Statins and Anticoagulants/Anti-aggregants. This form allows participants to learn in a fun way and to promote interactions.
To evaluate the impact of these sessions, the same quiz is filled out by the patients at the beginning and end of the session, in order to measure the improvement of their knowledge. This quiz is in the form of an evaluation grid, composed of 20 questions with binary answers (True/False) covering the concepts discussed during the activity. The answers allow the attribution of a grade out of 20.

What has been achieved?

33 game cards were created (12 cards for general questions, 8 for statins and 13 for anticoagulants/anti-aggregants, of which three concern anti-vitamin K).
The patients take turns drawing a card and think collectively. The correct answer is later explained by the pharmacist. At the end of the activity, forms summarising the points discussed are given to the patients.
Concerning the quiz, the evaluation of the impact of these sessions was carried out on a first group of seven patients. The average score was 14 (12-17) at the beginning of the activity and 17 at the end (15-20), thus an average improvement in knowledge of 21% (0-58%).

What next?

An analysis of the questions with the lowest rate of positive responses will help us to improve the messages during the activity. A treatment plan given to patients at the end of the session to help them take their medication is also being discussed.

Healthcare impact of a digital health programme for patients with chronic or high-frequency episodic migraine

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European Statement

Patient Safety and Quality Assurance

Author(s)

Anna de Dios-López, Neus Pagès-Puigdemont, Montserrat Masip-Torné, Pau Riera-Armengol, Rebeca Pelegrín-Cruz, Cristina Martínez-Molina, Noemí Morollón, Robert Belvís-Nieto, Maria Antònia Mangues-Bafalluy, Mar Gomis-Pastor

Why was it done?

Migraine is a neurological disorder characterised by frequent headache. Patients with an episodic migraine pattern have <15 monthly migraine days (MMD), whereas patients with a chronic pattern have ≥15 MMD. Migraine has a high prevalence (15-20% of female and 5-8% of male) and a great impact on their quality of life. Many migraine patients can benefit from preventive treatment. The use of a digital health programme in these patients can allow a real-time monitoring of treatment effectiveness (through the register of migraine attacks frequency) and adverse events. Additionally, it can improve the communication between patients and HCP.

What was done?

We tested a patients’ mobile phone (mHealth) application in chronic and high-frequency episodic migraine patients. This application was synchronically linked with a website for healthcare professionals (HCP) and hospital clinical records.

How was it done?

MyPlan is a mHealth application adapted from another one developed in our hospital for heart transplant patients. Firstly, we conducted a focus group with patients to understand their needs and preferences. This platform fulfils the quality and Data Protection Regulation.

What has been achieved?

13 patients and carers participated in two different focus groups. Another focus group was conducted with the Neurology Department of our institution. The results permitted to adapt the mHealth application with the following functionalities and registers:
• Synchronous (videocall) and asynchronous (direct message) communication between patients and HCP
• Medication adherence
• Treatment adverse events
• MMD and monthly headache days (MHD)
• Monitoring through the register of biomeasures (blood pressure, weight), lifestyle habits (diet, exercise) and questionnaires (MIDAS, HIT-6, EQ-5D, MSQ)
• Information
Data registered by the patient was used to guide clinical management and improve patients’ healthcare route.

What next?

The introduction of mHealth in the healthcare route of patients with migraine could benefit both patients and HCP. This strategy could be incorporated in other health facilities that attend migraine patients in an outpatient setting. Nowadays, a clinical trial is being conducted to demonstrate its clinical benefit.

Automated dispensing systems: improving and digitising medicines optimisation

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European Statement

Patient Safety and Quality Assurance

Author(s)

Easter Mark

Why was it done?

Medicines storage was low tech in a new high tech Private Finance Initiative (PFI) hospital and security was operationally heavy on nursing teams. The trust was on a journey to Electronic Patient Records (EPR). What was needed was a solution that bought both challenges together – how we implement improved medicines storage that fully leverage the power of a hospital EPR system.

What was done?

Trust-wide implementation of Automated Dispensing Systems, initially to drive safer and legislative compliance with storage. Since implementation, we have improved management of medicines during shortages, taken waste out of operational delivery around supply of medicines, informed teams around medicines safety during heat waves, and we are on a journey to closed loop medicines administration.

How was it done?

A business case recognising the reputational impact of poor Care Quality Commission (CQC) assessment of security, nurse led audit work recognising the impact of medicines handling on Time to Care and recruiting enthusiasts to support the programme.

What has been achieved?

All wards and departments have automated dispensing systems for medication storage – 72 units, including two in pharmacy for controlled drugs and after-hours support.
Medication Safety officer (MSO) used live view to track high risk medicines throughout Covid-19 and beyond. Never missed a dose of high risk medicines by utilising this technology over the Covid period.

Temperature monitoring gives an overview of real time temperature of all stock areas to support informed decision-making during hot and warm weather. Digital ordering by automated dispensing systems has reduced nurse time handling medicines by using pharmacy team time saved from ordering medicines redeployed to fill cabinets instead of nurses.
Increasing breadth of stock holding as top up thrice or more weekly rather than just weekly across Trust.

What next?

Planning benefits of integrating a robot dispensing system and hospital information system next spring. Robotic storage supporting real-time medicines management from stock to temperature all with enhanced security and removes process waste from process especially when combined with other digital initiatives. Trust Go-Live with Cerner in spring 2023 and use of cabinets to support closed loop administration.

Implementation of a standardised parenteral nutrition solution on a neonatal ward

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European Statement

Patient Safety and Quality Assurance

Author(s)

Isabelle Sommer, Farshid Sadeghipour

Why was it done?

PN can be composed of 14 different ingredients, including an amino acids admixture. Therefore, PN represents a complex and high risk preparation. Medication errors (ME) are often related to PN management and may include prescription, transcription, preparation, and administration errors. As the treatment with PN is essential for a good cerebral and neurologic development and a postnatal weight gain, ME can result in growth retardation, developmental disturbances, and infections. The implementation of the standardised PN aimed to achieve a reduction of ME having an impact on vulnerable newborns and to improve the security and quality of their nutritional treatment.

What was done?

A multidisciplinary development of a hospital’s neonatology and pharmacy departments as well as of an industrial manufacturer resulted in a standardised parenteral nutrition (PN) solution for neonatal patients. This PN solution was implemented as “standard-of-care” for newborn term and preterm infants requiring nutritional treatment within their first days of life.

How was it done?

The standardised PN solution for a peripheral administration route was developed in accordance with ESPGHAN guidelines (2018).
The neonatologists defined internal guidelines for the PN administration and trained the concerned personnel (physicians and nurses).
The industrial manufacturer delivered the ready-to-use PN solution as a sterile double-chamber infusion bag in accordance with Swiss and European regulatory.

What has been achieved?

The ready-to-use PN solution with a 24/7 availability on ward by means of an 18 months stability at room temperature allowed a considerable reduction (-80%) of on ward preparation of nutritional solutions by nurses.
One-third of individual PN solutions being prepared at the hospital’s pharmacy has been replaced by the standardised PN solution.
This high-quality PN solution allows a secured administration to the vulnerable patients as well as a reduction of ME related the whole PN management resulting in an improvement of the nutritional treatment of neonates and its outcomes on their development.

What next?

This special PN solution is already implemented in two Swiss university hospitals and others will follow. Further standardised PN for a central venous administration to neonates need to be developed to allow the completion of a safe nutritional treatment. On ward PN preparations must be prohibited to prevent undetectable ME.

Interdisciplinary follow-up of benzodiazepines withdrawal in primary health care

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European Statement

Clinical Pharmacy Services

Author(s)

Claudia Elias, Alda Morgado, Daniel Amaral , Fátima Cimadeira, Nadine Ribeiro

Why was it done?

Anxiolytics, sedatives and hypnotics consumption in Portugal represents 6,1% of the drug market (1). Their prescription, which should be limited in time, 12 weeks maximum, is often prolonged. As a result, patients experience cognitive deterioration, falling risk increase and tolerance and dependence. As a result, withdrawal phenomena occur, making it difficult to stop BZD. (2) Addressing this problem at the beginning of BZD use is important, avoiding chronic use.

What was done?

An interdisciplinary team was created, involving psychologist, a clinical pharmacist and a general practitioner (GP), of Primary Health Care (PHC) for patients with insomnia or anxiety who accept to participate in the benzodiazepines (BZD) Withdrawal process.

How was it done?

In December 2021, PHC’s GP started eligible patients selection and their referral. The dose reduction schedule is selected by pharmacists and agreed with GP. During the process, psychologists help patients developing skills to overcome psychological barriers; pharmacists monitor the withdrawal process, supporting deprivation management. The interdisciplinary team is in permanent contact, favouring successful withdrawal.

What has been achieved?

Eleven patients were appointed; eight remain in follow-up. Initial prescriptions started for anxiety, insomnia and depression episodes and were continued over time. Intercurrences in personal lives and concomitant therapies changes conditioned delays in withdrawal process. On average, we managed to reduce BZD dose by 25% every 12 weeks, requiring nine pharmacist appointments. Despite difficulties, patients’ motivation and effective BZD reductions and/or ending are the desired health outcomes, suggesting the success of this intervention.

What next?

Currently, we are adjusting the method and the referral process, minimising some of the difficulties faced. We are also presenting the project to new healthcare units, as we intend to guarantee equity in access to the BZD withdrawal programme for all eligible patients.

“Clinical research helpdesk”: an active support for investigators in a large university hospital

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European Statement

Clinical Pharmacy Services

Author(s)

Roberto Brunoro, Mariassunta Miscio, Girolama Iadicicco, Lorenzo Codato, Domenica Condello, Elisa Danieli, Viola Donadello, Alice Osto, Federica Pace, Giulia Valente, Francesca Venturini

Why was it done?

In our Italian University Hospital, we established the “Clinical Research Helpdesk” managed by the Clinical Research Unit. According to a daily schedule all personnel with an active role in clinical research can reserve an appointment with a pharmacist and administrative staff to ask questions for the submission of the necessary documentation for the Ethics Committee (EC) and for the evaluation of the study feasibility.

What was done?

In our Italian University Hospital, we established the “Clinical Research Helpdesk” managed by the Clinical Research Unit. According to a daily schedule all personnel with an active role in clinical research can reserve an appointment with a pharmacist and administrative staff to ask question for the submission of the necessary documentation for the Ethics Committee (EC) and for the evaluation of the study feasibility

How was it done?

The schedule is a Google Calendar tool which permits to generate slots of appointments. Researchers can access it by a link spread during a presentation event of the initiative. At each appointment the presence of a pharmacist for scientific counselling and a member of the EC scientific secretariat is guaranteed.

What has been achieved?

Since March 2022 the helpdesk accounts for 120 appointments with an average of 17 appointments/month. Typical questions are related to documental forms clinical trials rules and regulation counselling; in the last period support was requested also for practical issues, e.g., CE marking for investigational medical devices, feasibility evaluation, contract agreement and informed consent. After the helpdesk activation, the processing time for all the evaluation steps from the document presentation until EC submission, decreased by 50% compared to the previous year. The service increased study submission: the requests for evaluation of interventional studies received by the helpdesk increased by 15%, whilst for observational studies the percentage increase was 10%.

What next?

We are planning to expand this service to reach a complete management of clinical trials introducing a “RedCap team”, consisting of clinical pharmacists and biostatisticians who will help researchers in study design, Clinical Research Forms (CRFs) creation, statistical evaluation and data interpretation. A legal team for legal issues and contract agreement counselling will also be offered. The aim is to increase the visibility of our hospital, making it more attractive for clinical research.

Implementation of a multidisciplinary personalised medicine unit for pharmacogenetic testing

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European Statement

Clinical Pharmacy Services

Author(s)

Jorge Fernández-Fradejas, Matías Morín-Rodríguez, Eva Delgado-Silveira, Miguel Ángel Moreno-Pelayo, Ana María Álvarez-Díaz

Why was it done?

There is an increasing number of gene-drug interactions that have the potential to predict patient response. Although the study of some genetic variants can be a useful tool to achieve a safer and more effective pharmacotherapy, the integration of personalised medicine in clinical practice has been challenging over the years, mainly due to prescriber’s scepticism and lack of clinical guidelines and protocols.

What was done?

We have implemented a multidisciplinary Personalised Medicine Unit (PMU) at a third- level hospital to facilitate preemptive pharmacogenetic testing.

How was it done?

The PMU provides its service with the involvement of Pharmacy and Genetics Department according to the following workflow:
1. Physicians order the pharmacogenetic test in the first contact with a patient expected to be treated with a drug with an available pharmacogenetic test.
2. A peripheral blood sample is drawn for DNA extraction and analysed by the Genetics Department.
3. An integrated pharmacogenetics report is generated and uploaded to the patient’s electronic medical record. This report contains the molecular information and its interpretation (responsibility of Genetics Department) and the clinical pharmacotherapeutic recommendation according to the results obtained (responsibility of Pharmacy Department). Dose adjustment recommendations follow the Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines and Dutch Pharmacogenomics Working Group (DPWG) guidelines.
4. Pharmacy Department follows up pharmacotherapeutic recommendation acceptance and clinical outcomes.

What has been achieved?

Since July 2021 we have implemented pharmacogenetic testing for seven drug-gene interactions:
July 2021. CYP2C9 – Siponimod.
November 2021. DPYD – Fluoropyrimidines (capecitabine, fluorouracil, tegafur).
April 2022. UGT1A1 – Irinotecan, liposomal pegylated irinotecan, sacituzumab govitecan.
Three hundred and seventy patients have benefited from pharmacogenetics testing. These tests have been requested by three different clinical departments and had a mean turnaround time of less than 10 days, preventing any potential treatment delays. An integrated Pharmacy-Genetics report with individualised pharmacotherapeutic recommendations was generated for every patient. These recommendations had an acceptance rate of 100%.

What next?

Since the creation of the PMU, we have been able to implement pharmacogenetic testing in clinical practice with a high level of acceptance. Our next challenges are introducing next- generation sequencing for the study of new gene-drug interactions in the unit portfolio and achieve a deeper integration of pharmacogenetic information in clinical decision support systems.

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BOOST is where visionaries, innovators, and healthcare leaders come together to tackle one of the biggest challenges in hospital pharmacy—medicine shortages.