Author(s)

Luis Díaz Suárez, Elena Sánchez-Yanez , Raquel López Escoz, Mercedes Gómez Delgado, Nuria Martínez Casanova, Isabel Moya Carmona

Why was it done?

The hospital pharmacist plays a role obtaining therapeutic success by improving the adherence. Our unit attends around 1900 HIV patients, so the interventions we make to improve adherence will have a positive impact on patients and community.

What was done?

The Pharmacy Service has developed a protocol for the identification of non-adherent HIV patients to treatment along with the pharmaceutical attendance strategies designed to improve the adherence to ART.

How was it done?

The protocol was drawn up with the recommendations of the National AIDS Plan(PNS), the Spanish Society of Hospital Pharmacy(SEFH) and the AIDS Study Group(GeSIDA). Thus, we wanted to provide a multidisciplinary approach for non-adherent patients. The relevant aspects of the protocol are described below:

1.-Identification of patients: Technical staff and pharmacists identify patients with poor adherence through dispensing records, a history of previous voluntary abandonment of ART or the presence of risk factors for poor adherence to ART.

2.-Pharmaceutical attendance following the CMO model.

· Data such as viral load, CD4, prescribed ART, pharmacotherapeutic complex index, home medication, polypharmacy, pluripathology and risk factor have
been collected. Adherence was calculated using dispensing records and adherence questionnaire(SMAQ).

· Health education and motivational interviewing.

· Personalised planning of patient care following face-to-face and non-face-to-face programs. Every 6months adherence will be re-evaluated to assess the
success of the pharmaceutical care offered.

What has been achieved?

The protocol was implemented in March-2021, and to date, 68patients have been included. 73.5%(n=50) of them have been followed for more than 6 months. 88% of whom(n=44) improved their adherence to both ART, all of them achieving an undetectable viral load and an elevation of the CD4 count.

What next?

Our desire is to continue detecting patients and to contribute to the improvement of the adherence to their treatment. We are aware of the challenge that lies ahead in the near future, as the progressive ageing of the HIV population means an increase in associated comorbidities and polypharmacy, which may have a negative impact on the adherence.

Author(s)

CLARA NOTARIO DONGIL, ALEJANDRO MARCOS DE LA TORRE, MARÍA CARMEN CONDE GARCÍA, MARÍA MAR ALAÑÓN PARDO, BEATRIZ PROY VEGA, NATALIA ANDRÉS NAVARRO

Why was it done?

Most of the cultures performed in outpatients were not reviewed or were reviewed too late. An early detection for an adequate control of multidrug-resistant bacteria and the setting of a targeted antibiotic treatment, in case of being necessary, was the aim of this project. Hence basis for the implementation of an ASP is laid down, giving also advice to medical staff regarding appropriate antibiotic treatments.

What was done?

Multiresistant bacteria containment is a public health priority. Antibiotic Stewardship Programs (ASPs) can help to enhance patient outcomes by improving antibiotic prescribing. ASPs are common in hospitals, but are not usually available in primary care.

How was it done?

1- A circuit between microbiology laboratory staff, preventive medicine and pharmacy service was done. The first two collaborated by presenting data from lab results.
2- Cultures of multidrug-resistant species of outpatients were included. Results were interpreted by a hospital pharmacist on a daily basis.
3- A circuit of telephone calls between pharmacy and primary care was settled in order to communicate high epidemiological impact species detected. Pharmacist collaborates by giving advice regarding the right drug, right dose and right time, only when antibiotic treatment was necessary. Reports were registered on the medical history.
4- Variables collected in database were: age, sex, institutionalized, antibiotics received, kidney disease, culture type, specie.

What has been achieved?

During five months, 52 patients were included (52% male, 48% female). Mean age: 68 years. 11% institutionalized patients. 31% presented kidney disease.
Urine culture (58%),skin culture (13%), bronchial/sputum culture (12%), stool culture (12%), , and other cultures (5%) were analysed. Multidrug-resistant species (spp) were: Klebsiella spp (34%); Pseudomonas spp (8%); Mycobacterium spp (6%); other spp (52%).
17 pharmacist interventions were carried out, all of them related to appropriated treatment. 2 patients were hospitalized in order to receive parenteral antibiotic.

What next?

Optimizing antibiotics use is important to effectively treat infections. Identifying species that generate therapeutic difficulties is essential. Pharmacist advice could reduce treatment failures applying efforts to improve antibiotic use, being link of union between hospital and primary care. Other activities such as providing training to medical staff or spread results regarding to the use of antibiotics will be critical for ASP development.

Author(s)

Andrea Costa-Navarro, Emilio Monte-Boquet, Mª Jesus Cuellar-Monreal, Ana Garcia-Robles, Eduardo Guerrero-Hurtado, Alejandra Ferrada-Gasco, Octavio Ballesta-Lopez, Andres Cruz-Sanchez, Jose Luis Poveda-Andres

Why was it done?

Complex medication regimens (MR) are associated with worse treatment adherence. The Medication Regimen Complexity Index (MRCI) is a validated tool used to quantify complexity of MR and it is the sum of the score in three sections: Dosage forms (A), dosing frequency (B) and additional directions (C).

What was done?

To assess the relative MR complexity among solid organ transplant patients (SOT; kidney, heart, lung and liver) in a tertiary hospital through the validated MRCI Spanish version.

How was it done?

Transplant patients who collected medication in the Hospital Pharmacy between January and March 2021 were selected. A total amount of 40 patients (ten per transplant) were chosen randomly through Excel®, and a macro with a template of MCRI was created. The qualitative variables were age, sex and type of transplant; the quantitative ones were months from transplant, total amount of medications, sections A, B, C and total MRCI. All prescribed medications documented in medical records at the hospital ambulatory clinics and the electronic medication list were included. Patients were excluded if they were followed-up in other hospitals, were exitus or MR dosage or frequency was missed/unclear. Subgroup analyses was made to assess MRCI among type of transplants through ANOVA. All data analysis were made with SPSS® version 23, with a <0,05 significance level and a confidence interval of 95%.

What has been achieved?

Sample median age was 56,6±14,7 years (95%CI:51,9-61,3), a 40%(16/40) were women, median of time from trasplant was 92,7±69,9 months (95%CI:70,4-115,0) and number of medications 11,1±4,6 (95%CI:9,6-12,6). Subgroup median MCRI were 23,3±10,2 (kidney; [95%CI:16,0-30,5]), 46,2±12,8 (lung; [95%CI:37,1-55,3]), 28,5±11,1 (heart; [95%CI:20,6-36,4]) and 18,7±5,4 (liver; [95%CI:14,8-22,5]). Section B was the most contributor to MCRI (16,6±8,2 [95%CI:14,0-19,2]), followed by C (6,6±4,3 [95%CI:5,2-7,9]) and A (5,7±3,7 [95%CI:4,5-6,9]). Tukey test showed a statistically significant MCRI in lung transplant with p<0,001 when compared to kidney and liver transplants, and p=0,002 compared to heart transplant.

What next?

Medication regiment of our sample was more complex in lung patients than in any other SOT, therefore these patients could benefit more pharmaceutical interventions. Further studies with bigger samples are required to confirm differences among kidney, liver and heart transplants.

Author(s)

Helen Cooper, Sheatha Abumehdi

Why was it done?

A lack of licensed formulations for children means that use of unlicensed and off-label medicines is often the only appropriate alternative [1]. Local prescribing data demonstrates wide variability in concentrations of unlicensed specials supplied, at significant cost. This project aims to standardise medicines prescribing for children, improve patient safety by reducing inadvertent dose misadministration due to varying concentrations, reduce spend, and improve the effectiveness of working relationships between hospital and community healthcare teams.

What was done?

Prescribing and procurement data were used to analyse, review and harmonise paediatric prescribing practices in a UK clinical commissioning group, with focus on rationalising use of unlicensed specials.

How was it done?

A target list of ten medicines was identified, based on variability of strengths and formulations available, and cost. A team of two dedicated specialist paediatric hospital pharmacists was funded to set out strategies to standardise prescribing of those target medicines, and to improve understanding of prescribing and supply of unlicensed medicines to children. Various methods were used, including; email communications advertising the roles and support offered; establishing a Paediatric Formulary Group; promoting the local Paediatric Formulary; creating paediatric prescribing pathways; reviewing specials prescribing and supporting switches to alternative formulations; and delivering a paediatric prescribing webinar.

What has been achieved?

Reviews of specials prescribing were initially undertaken in two of the six boroughs in the region. 138 switches to a preferred formulation for safety and/or cost-effectiveness were identified and discussed between July-October 2021. Risks associated with prescribing multiple concentrations of liquid medicines were identified and measures were put in place to prevent patient harm. The webinar was well attended, and although it cannot be quantified, awareness of the Paediatric Formulary has improved. The project is on-going and at this time the impact on spend cannot be shown but will be reported later this year.

What next?

The specific knowledge and skills of specialist paediatric hospital pharmacists are highly valuable in driving specials medicines rationalisation for children in the community. Future plans for expanding the project include extending the service to other boroughs in the region and widening the target list of medicines.

References: 1.Rawlence E et al. Is the provision of paediatric oral liquid unlicensed medicines safe? Arch Dis Child Educ Pract Ed. 2018;103(6):310-3. 2.Neonatal and Paediatric Pharmacists Group. Position Statement 18-01 Using Standardised Strengths of Unlicensed Liquid Medicines in Children. Version 5, April 2020.

Author(s)

Marta García-Queiruga, Begoña Feal-Cortizas, José María Gutiérrez-Urbón, Andrea Luaces-Rodríguez, Alejandro Martínez-Pradeda, Sandra Rotea-Salvo, Carla Fernandez-Oliveira, Víctor Giménez-Arufe, Luis Margusino-Framiñán, Isabel Martín-Herranz

Why was it done?

Daptomycin is an intravenous antibiotic usually prepared in Hospital Pharmacy services. Normally it is dosed based on body weight, which requires each intravenous mixture to be prepared in an individual manner for each patient. This might lead to an increased assistance workload in elaboration areas, a higher number of errors in the preparation and high costs due to waste materials generated during preparation.

What was done?

The aim of this study is to describe the preparation of intravenous daptomycin by dose banding, a system in which daptomycin doses are rounded up or down in order to standardize and protocolize the preparation of intravenous mixtures as much as possible.

How was it done?

In order to improve this situation, dose banding strategy was implemented in February 2019: the obtained final dose was rounded in such a way that only mixtures of 500, 700 and 850 mg were prepared (in agreement with Hospital Pharmacy and Infectious and Microbiology medical teams) , following this scheme:
PRESCRIBED DOSE PREPARED DOSE
< 400 mg Prescribed dose (individualized) 400–599 mg 500 mg ≥600–799 mg 700 mg ≥800 mg 850 mg

What has been achieved?

Previous year before starting dose banding strategy (2018), 5493 individualized doses of daptomycin were prepared for 437 patients in our Pharmacy service. Between June 2020 and June 2021, 2680, 2555 and 997 units of daptomycin 500, 700 and 850 mg, respectively, were prepared for 360 patients. Batches of standardized doses were prepared in advance and kept refrigerated (stability of 10 days in 100 ml of physiological saline) until dispensation. In addition, during the same period, 15 patients (4 from pediatrics) received 209 individualized doses (3.2% of the total doses) due to their low body weight.

What next?

This strategy might decrease the number of errors in preparation and reduce processing times, which is essential since early appropriate antibiotic treatment in severe infection has been associated with better outcomes. Dose banding model could be extrapolated to other drugs with good physical, medical and microbiological stability in dilution, which are frequently prescribed and when few dose bands can cover most of the prescriptions.

Author(s)

Paula Hernando Martínez, María Antonia Meroño Saura, Caridad Marti Gil, Lidia Martínez Valdevieso, Jaime Fernández-Bravo Rodrigo, Dolores Barreda Hernández

Why was it done?

There is a wide bibliography on how human errors related to drugs put the patient’s health at risk. Drug preparation and administration errors, dose calculation errors, lack of knowledge about drugs or interactions, to name but a few. There must be protocols to ensure that drugs are safe for patients, including procedures which professionals should fulfill in order to reduce those errors in processes and guarantee, in such cases, that they will not have adverse effects on patients.

What was done?

Development of infographics for assembling drugs which are susceptible to a higher rate of errors in their preparation and administration to hospitalized patients.

How was it done?

During September 2021, a working group was formed in the pharmacy department (PD). Through the nominal group technique, the design and content of drug infographics was proposed as a solution to the raised problem. Subsequently, a bibliographic research of susceptible drugs to human errors during administration or preparation and those which requiring special handling was reviewed through the list of high-alert medication from National Institute for the Safe Use of Medications website and NIOSH list of hazardous drugs. To this end, the PD databases were analysed, obtaining the drugs that required the greatest number of pharmacotherapeutic consultations made by nursing staff on drug administration and recommendations made during pharmaceutical validation.

What has been achieved?

An infographic model has been designed which includes the description of the drug (name of drug, excipients, dose, pharmaceutical form, dosage regimen, route of administration, concentration), the preparation and administration protocol (reconstitution, dilution, infusion rate, premedication), observations (maximum doses, conditioning, incompatibilities, alerts) and storage conditions (conservation and stability). Infographics on dantrolene, intravenous phenytoin solution, intravenous nimodipine solution and potassium chloride solutions are currently being distributed. These documents are available at the nursing controls and on the hospital’s internal website.

What next?

To increase the availability of drug’s infographics and to update those that have already been developed when necessary. In addition, from the PD, the preparation of administration kits for the solicited drugs is proposed so as to ensure that all the necessary materials for the preparation and administration are included along with the corresponding drug and infographic.

Author(s)

Esteban CHAUMET, Johanna RAYMOND, Eric BARAT, Catherine CHENAILLER, Rémi VARIN

Why was it done?

A clinical study, including a PI focused on the management of acute non-cancerous pain with opioids, was implemented in post-emergency units of our teaching hospital. Formation and empowerment procedures for PIs are little or not described in the literature. Given the multiplicity of actors, which could perform those PIs, it appeared necessary to standardize our practices and key messages delivered to the patient.

What was done?

Create an adapted formation allowing standardization of practices between various actors performing a pharmaceutical interview (PI) focused on the management of acute non-cancerous pain with opioids.

How was it done?

Creation of different tools : a resource pack with opioids literature to train learners; a theoretical and practical formation schedule and an empowerment procedure, supervised by a qualified tutor; an interview frame with topics to be addressed during the PI; two audio simulations of patient interviews; complex questions that the patient might ask during the PI.

What has been achieved?

The resource pack contains 11 documents that provide the learner with relevant concepts and the key messages to deliver to patients. The formation schedule consists of several stages. Firstly, theoretical formation : learning with the resource pack; written restitution of knowledge on the interview frame and identification of the points to be improved with the tutor; completion of the e-learning on performing a PI (currently being created by the French Society of Clinical Pharmacy); listening to the two audio simulations and oral restitution of information to the tutor; restitution by the learner, during a reversed class, of knowledge on opioids and key messages for the patient; answering complex questions. The practical formation consists of observing the tutor during a PI, then performing PIs with a qualified tutor.

What next?

The formation and empowerment will be implemented in November 2021. As part of a quality approach, learner’s satisfaction and general appreciation will be collected in order to optimise the formation. The creation of this procedure will guarantee a uniform, complete and modern formation based on a quality system thus minimising the biases induced by the multiplicity of actors performing the PIs. In the future, this formation schedule and empowerment could be adapted to other PI topics.

Author(s)

Ugo CARRERE, Charles-Henri BLANCHER, Julien ARCIZET, Serge BENETEAUD, Caroline ALLIX-BEGUEC, Benoit LE FRANC

Why was it done?

EDs are the main entry point for hospitalizations. Medication errors are a major threat to patients safety. They are exacerbated by the high flow of patient admitted, the increase in polypharmacy in eldery patients, lack of knowledge of medication and time constraints.

What was done?

We have implemented proactive medication reconciliations (MR) for eldery patients in our emergency department (ED). Retroactive MR was performed in downstream departments (DD) for similar patients. Goals were to save physicians’ and nurses’ times, to improve patient safety.

How was it done?

A pharmacist provided MR in the ED unit three half-days per week. In agreement with the emergency physicians, we targeted patients aged 75 years and over and/or 65 years and over with multiple medications remained hospitalized. Pharmacists collected patients’ medication history and shared the information to ED prescribers. The drug assessment was recorded in a prescription support software. Prescribers, in the DD, could use it to prescribed without transcription and save time.
Our study was based on the comparison of the two groups : the proactive MR group in the ED and the control group with retroactive MR in downstream departements. Discrepancies were recorded and rated as intentional and unintentional in the two groups.

What has been achieved?

Between February and April 2021, 139 medication reconciliations were performed (proactive group n=61 ; retroactive group n=78). The age (about 83 years) and mean number of drugs per patient (about seven) of the two groups were not statistiquely different. We observed a statistically significant reduction in the number of unintentional discrepancies with proactive reconciliation in the ED (7% in the proactive group versus 20% in the retroactive group, p-value = 0.0034). Drugs for the nervous system and the cardiovascular system were the most affected by discrepancies. These discrepancies were mainly detected in prescriptions for patients taken care in the orthopedic surgery, the hepato-gastrology and the polyvalent medicine departments.

What next?

Clinical, economic and organizational scoring of unintentional discrepancies will be performed by a physician-pharmacist pair (CLEO scale of the French Society of Clinical Pharmacy)
Downstream departments with the most UD will be encouraged to use medication reconciliation.
A satisfaction survey will be conducted among the teams.

Author(s)

QUERALT LOPEZ NOGUERA, ÀNGELA CASTELLÓ NÒRIA, CRISTINA DIEZ VALLEJO, LAURA VIÑAS SAGUÉ, MARTA COMA PUNSET, SILVIA CABARROCAS DURAN, MIREIA VILA CURRIUS, ANNA DORDÀ BENITO, EDUARDO TEJEDOR TEJADA, CRISTINA TORO BLANCH, ROSA NURIA ALEIXANDRE CERAROLS, ROSA SACREST GÜELL

Why was it done?

The declaration of the state of emergency by SARS-CoV-2 pandemic on March of 2020 had an impact on hospital PC.
During that period, it was advised by Healthcare Authorisations to minimize the risk of infection or spread of SARS-CoV-2 in order to protect vulnerable groups. For that reason, it was not recommended to assist in the hospital if it was not necessary. This fact caused some organizational changes in OPC to adapt to the current situation.

What was done?

Our hospital Pharmacy Department created a telepharmacy service in outpatient’s pharmaceutical consultation (OPC) after state of emergency declaration by SARS-CoV-2. We created a standard operating procedure working together with communitarian pharmacists and the Region Pharmacist’s College. The main aim was to ensure pharmaceutical care (PC) quality in vulnerable patients and the correct medication distribution and conservation. Pharmaceutical care was developed by telephone call and medication was send to communitarian pharmacy.
A comprehensive analysis was made to concern the impact on drugs delivery selecting certified distribution company which ensured drug traceability, custody and conservation.

How was it done?

In 2020, approximately 60 patients per day used to attend in OPC. According to the large number of patients, we defined which patients could take advantage of this programme. The selection criteria were adherent patients with pulmonary pathologies (cystic fibrosis, asthma, bronchiectasis, etc.), multiple sclerosis, amyotrophic lateral sclerosis, reduced mobility or patients over 65 years old who lived in more than 30km closed to the hospital or without any family member that could come.
In order to ensure the process traceability, an informatics tool has been created by Region Pharmacist’s College. Pharmacy Department, community pharmacy and the distribution company assumed all expenses.

What has been achieved?

369 of 2.346 patients were included in our telepharmacy service during the state of emergency. There was high level of acceptance by all patients. Only low-risk patients or patients who had an on-site doctor visit were attends in OPC. Nowadays, 196 patients still benefit from the initiative.

What next?

Telepharmacy program avoids patient’s displacements that are particularly susceptible to COVID-19 negatives effects. Moreover, it guarantees PC quality, patient’s adherence, process traceability and correct medication conservation from hospital to patient’s home.

Author(s)

Quentin Misandeau, Romain Bosc, Muriel Paul, Valérie Archer, Lionel Tortolano

Why was it done?

The plastic surgery department bought two 3D printers in order to design and create custom-made medical devices. The main objective was to decrease the delay between mandibular cancer diagnosis and the surgery. The delays of production in the medical device manufacturers may exceed 2 weeks. Those delays are considered as a lost of chance for the patients.

What was done?

We helped our surgeons to secured the production procedure and reduce the risks for patients. We create a management quality system for supply, production, sterilization and using of our homemade personalized 3D printed guides.

How was it done?

First, we created a task force of pharmacist and surgeons.
The main work was a risk analysis with the FMECA method for all the steps in the procedure (software, tools, actors and materials).

What has been achieved?

Some correctives actions were taken. The riskier points were the plastic materials toxicity risk, the sterilization procedure that has been validated and the production traceability. A biocompatibility evaluation was performed. A clinical evaluation has been initiated in the same period.

What next?

Since the new medical device regulatory (2017 /745 CE) was published in 2017, the article five, that regulate the 3D printing in hospital, changes the possibilities. In fact, as personalized 3D printed guides are available on the EU market, homemade personalized 3D printed guides for mandibular reconstruction could be not authorized anymore. The only way would be for the hospital to obtain the regulatory statut of manufacturer and comply with the essential requirements.