Author(s)

Nicolas Sagaria, Daniele Mengato

Why was it done?

Dysphagia is a swallowing disorder more common in the elderly. The pharmaceutical market is not always able to meet the needs of dysphagic patients and manipulation of a medication is sometimes the only possible way to ensure its administration. This activity is often delegated to nurses or other professionals without the necessary education.

What was done?

The manipulation of solid oral pharmaceutical forms, such as tablets or capsules, is such a common act that it is sometimes regarded superficially. In order to guide the clinical pharmacist in assessing the crushability of a tablet, we designed, and validated through an on-field application, a decision-making algorithm.

How was it done?

The first two steps of the algorithm help, respectively, to understand whether there are clear indications in the summary of product characteristics on how to manipulate the drug and/or whether there are alternatives on the market, other than the solid oral, suitable for administration to the dysphagic patient. When neither of these steps is feasible, the pharmacist is guided towards direct manipulation of the drug, supported by evidence in literature and study of excipients. If a solution cannot be found, the physician should be advised to consider a switch or a discontinuation of therapy. Finally, we tested the algorithm by including it in a medication review form in a otolaryngology-ENT department, where the incidence of dysphagic patients was higher.

What has been achieved?

In the second half of 2020, we analyzed 45 medrev forms filled out in the ENT-department. Each form contained an average of 2.8 drugs to be re-analyzed for the dysphagic patient. We applied our algorithm to a total of 123 drugs. For 101 (82%) of these, we provided precise information on the correct way to administer and manipulate the drug. For only 22 drugs, a discussion with the prescriber was necessary to identify an alternative. In this way we have improved patients’ and operators’ safety.

What next?

In the near future we will expand our test to other departments, not only surgical, and try to minimise the rate of drugs for which we could not provide information on manipulation. In addition, we are planning to develop a software to simplify the process.

Author(s)

Jon Michaeli, Bryan Li

Why was it done?

The novel delivery method provides an on-demand option for senior citizens at higher risk of serious Covid-19 infections to receive health essentials while maintaining social distancing. The program launched before Covid-19 vaccines were publicly available, and was sustained during a period of especially intense Covid-19 spread in the US from Nov 2020 – Jan 2021.

What was done?

In early May 2020, Matternet, CVS, and UPS launched direct-to-consumer drone delivery of prescription medicines and other health goods to The Villages, the United States’s largest retirement community with more than 135,000 residents. The operations have expanded in scope since and are ongoing

How was it done?

The drone flights were conducted by Matternet’s M2V9 UAV platform and drew upon the companies’ experience operating other US healthcare drone networks. Deliveries are dispatched from CVS store 8381 and flown to New Covenant United Methodist Church, with final delivery to front porches via golf cart. This is an important milestone on the journey to drone delivery to individual homes at scale.

What has been achieved?

Matternet and UPS have completed 2,500+ deliveries to date. The partnership has expanded operations to Elan Buena Vista, another retirement community nearby. The program’s success helped pave the way for other healthcare drone programs, including a new route at Wake Forest Baptist where Matternet and UPS are transporting Pfizer-BioNTech Covid-19 vaccines (first ever in the US).

What next?

Full automation achieved via Matternet’s proprietary drone port, the “Station,” will permit pharmaceutical drone delivery at scale and accelerate the roll-out of city-wide networks that give pharmacists more flexibility around where and how patients receive medicines. These networks will support and accelerate the shift to tele-health and “hospital at home” as well as just-in-time inventory management, with significant potential to reduce medical waste through stock centralization. First commercial deployment of the Station occurred in Lugano, Switzerland in September 2021. The same month, Matternet announced a partnership with the Abu Dhabi Department of Health and the UAE’s General Civil Aviation Authority to launch a city-wide medical network serving 40+ locations by 2023. Similar systems are planned for Europe, in cities such as Zurich, Berlin and Athens.

Author(s)

Mireia Iglesias Rodrigo, Júlia Pardo Pastor, Alba Manzaneque Gordon, Cristina Sangrador Pelluz, Núria Meca Casasnovas, Clara Sebastián Carrasco, Fernando Salazar Gonzalez, Gemma Garreta Fontelles, Jordi Nicolás Picó

Why was it done?

Due to the risk posed by the handling of Hazard Drugs (HD) in the healthcare field, it is necessary to implement circuits that guarantee the professional’s safety.

What was done?

Create an internal classification of HD based on the NIOSH List of Hazard Drugs in Healthcare Setting 2020, to optimize the circuit of its handling from its receiving to its administration.

How was it done?

Considering the HD included in the Pharmacotherapeutic Guide (PTG) of our center, the stages of reception and adaptation/preparation/dispensing/administration and other precautions were analyzed.
Categories were established, analyzing the needs of each stage according to: NIOSH level of danger, setting (inpatient/outpatient), pharmaceutical form, commercialized pharmaceutical specialties or available alternatives, and material/personal resources.
Prior to its implementation, e-learning training was carried out for the healthcare professional involved.

What has been achieved?

A total of 25.3% (379/1498) of the pharmaceutical specialties included in PTG were HD. Thirteen HD groups were identified. Due to the fact that in the outpatient setting the drug is dispensed to the patient in its original container, the actions implemented were only carried out for inpatients, representing these 9/13 of described groups. The established training was carried out by the 89% of professionals. Proposed measures for HD are summarized in Table 1.

What next?

Monitoring and evaluation of the circuit

Author(s)

Petra Rozsívalová, Věra Zdanovcová, Lenka Beková, Martina Maříková, Marcela Heislerová, Vladimír Koblížek, Petr Šmahel

Why was it done?

By implementing systematic monitoring in our institution, CPs ensure appropriate and safe use of unlicensed treatment available under Emergency Use Authorisation. The secondary goal is mandatory data input to national register and patient clinical outcome feedback to physicians and hospital management.

What was done?

It is vital to bring focus on appropriate use of COVID-19 monoclonal antibodies (mAbs) in high-risk population when safety and efficacy data are scarce. A team of clinical pharmacists (CPs) helped to set up process flow, monitor prescribing of mAbs and provide systematic follow-up on time course of symptoms reported by SARS-COV-2 positive outpatients since March 2021.

How was it done?

Ethics committee approval was obtained for monitoring of patients. Consented patient data are extracted from electronic prescribing system and patients score subjective symptoms using questionnaire on days 7, 29 and 90 after the infusion. The prescriber, indication criteria, infusion application day with regards to PCR positivity and symptom onset and vaccination status are recorded.

What has been achieved?

Currently our small dataset includes 59 bamlanivimab and 63 casirivimab/imdevimab patients. On average, mAbs are administered within 2 days of positive PCR test and 5 days of COVID-19 symptoms onset. Our patients report subjective improvement in symptoms by 7 days post infusion. None of our patients clinically deteriorated because of COVID-19. 100 % of mAbs administered are reported in the national database. In October 2021 we achieved that laboratory confirmed positive patients receive text message with infectionist contact to discuss eligibility for mAbs on 24/7 basis. CPs also implemented information leaflets on mAbs for patients with chronic conditions.

What next?

To date, there are no published descriptive data on real-life utilisation of COVID-19 mAbs in terms of patient characteristics, disease outcome and vaccination status. Our initiative shows na excellent opportunity for CPs to enhance timely and rational mAbs use.

Author(s)

Catarina Oliveira, Ana Mirco, Fátima Falcão

Why was it done?

-lactams have proven to be effective and safe antibiotics over their history, and as a consequence, these drugs are typically among the most frequently prescribed in hospital settings. Optimization of treatment with β-lactams can be achieved by their administration by continuous infusion. Furthermore, this approach leads to a reduction of the nursing time devoted to preparation and administration. However, information regarding continuous infusion of β-lactams is not readily available for most antibiotics, leading to doubts about dosing, renal adjustments and administration, particularly uncertainties related to dilution of the antibiotics as most patients benefit from fluid restriction. Also, it was indispensable to understand which antibiotics had stability to be administered through continuous infusion.

What was done?

A protocol for continuous infusion of β-lactams was established in a coronary care unit (CCU), replacing the previous method of intermittent dosing in most patients.

How was it done?

Firstly, we evaluated which antibiotics benefited from this approach and had, simultaneously, stability. The antibiotics selected were Cefotaxime, Ceftazidime, Cefepime, Cefuroxime, Piperacillin/tazobactam, Penicillin G, Ampicillin and Flucloxacillin. In order to stablish a protocol for continuous infusion of these antibiotics, an extensive literature review was performed. Information about loading and maintenance dose, reconstitution, dilution (solvent and maximum concentration), infusion rate, renal adjustments, stability and storage was collected and summarized in a table.

What has been achieved?

A ready-to-use version of the β-lactams continuous infusion protocol was developed. In addition, dosing adjustments in patients on continuous renal replacement therapy, commonly made in patients in the CCU, were included too. This protocol was made available to all health professionals through the hospital’s intranet as well as posted in the CCU in order to be easily accessible by doctors and nurses. Thus, continuous infusion is now the standard for most patients requiring therapy with β-lactams in the CCU.

What next?

The implementation of this protocol has an education purpose, allowing the best use of documented practices in prescribing, medication review and administration continuous infusion of β-lactams. This protocol can similarly be easily implemented in other medical units. In the near future, we plan to monitor the compliance to the protocol and consider further improvements if necessary.

Author(s)

Alina Shramko, Veronika Haziahmetova

Why was it done?

Based on the results of the analysis, it is possible to answer the question whether it is advisable to spend financial resources, using the example of one healthcare facility; what steps should be taken to rationalize drug procurement; which drugs should be considered first of all for inclusion/exclusion from the procurement list.

What was done?

Currently, ABC/VEN analysis is one of the most effective pharmacoeconomical methods recommended by WHO for the use in the healthcare system. The use of pharmacoeconomic methods is carried out in accordance with the inherent effective use of drugs, and is carried out strictly in accordance with the principles of evidence-based medicine.

How was it done?

The ABC/VEN analysis was conducted based on data from the pharmacy of the LPI containing the costs of purchasing medicines during 2020. The VEN category was determined after a thorough review of the evidence available to us about the effectiveness, safety and cost of drugs.

What has been achieved?

The cost of drug provision to healthcare facilities in 2020 amounted to 62 943 951,38 rubles. The number of international generic name purchased and used was 355. About 35% of the funds were used for a group of vital medicines. The cost of the necessary medicines amounted to 43% of the funds – this corresponds to WHO recommendations.
In accordance with the ATX-classification, drugs affecting blood formation and blood are in the lead in terms of the volume of costs – 40.9% of all costs.
The drug is enoxaparin sodium, the leader in terms of costs in 2020. It is a direct anticoagulant (low molecular weight heparins with a molecular weight about 4500 daltons), which has an antithrombotic effect (2.38% of the total budget).
Also, the top ten leaders in terms of costs included saline sodium chloride solution – 6.1% of the annual budget, which probably indicates irrational excessive use of infusion therapy.

What next?

The application of pharmacoeconomical methods and principles of evidence-based medicine allowed us to assess the feasibility of drug procurement and serves to rationalize the use of medicines.

Author(s)

Eugenia Serramontmany Morante, Patricia Garcia Ortega, Lorena Garcia Basas, Pablo Latorre Garcia, Pilar Rovira Torres, Laura Maños Pujol, Isabel Cidoncha Muñoz, M. Queralt Gorgas Torner

Why was it done?

The provision of outpatient oncology services by pharmacists is still limited, but it is an emerging role. It can add value while increasing the quality of patient care required, maximizing the likelihood of achieving positive outcomes and thus improving the patient’s quality of life. It is important to incorporate clinical pharmacists into outpatient clinics to ensure the safe use of investigational drugs and guarantee the best treatment for the patient.

What was done?

The oncology clinical trials pharmacy team initiated an outpatient clinic at a tertiary hospital. This enabled review of patients’ medications, monitoring of interactions, appropriate oral chemotherapy counseling, design of medication diaries and instructions, discussion of side effects, as well as other dietary and daily living recommendations.

How was it done?

A multidisciplinary team was formed: pharmacy, medical, nursing, ancillary and administrative staff, to discuss circuits and strategies to address outpatient pharmacy clinic.
The pharmaceutical care program was implemented gradually during 6 months, first in phase I, then phases II and III clinical trials.
Factors including appointment scheduling, patient prioritization, clinic room availability as well as detailed definition of pharmaceutical activity were discussed, in order to have a standard procedure for all patients included in a clinical trial.
The group continued to meet weekly to further discuss the progress of the pharmaceutical care program and any obstacles and unforeseen events.

What has been achieved?

Medication has been dispensed to 8447 patients in the outpatient pharmacy, of which 1172 patients have been attended by the clinical pharmacist during the first 8 months (January-August 2021) of the programme’s implementation.
Pharmaceutical care at the first day of treatment has been provided to 275 patients to explain how to take the treatment and resolve doubts. The concomitant medication of 312 patients has been reviewed for the screening and 425 telephone queries about concomitant medication have been resolved.

What next?

The evolutionary change in cancer care along with the increase in the number of clinical trials and its complexity will emphasize the need to include the oncology pharmacist in the cancer care team. The role of a clinical pharmacist is vital to ensure the safety and controlled use of the drug, ensuring the best possible outcomes.

Author(s)

Julia Santucci, Céline Vaesken, Guillaume Saint-Lorant

Why was it done?

FMT is a therapy introduced in 2016 at the hospital. It is indicated for the management of recurrent and refractory Clostridioides difficile (CD) infections. In November 2020, with the resumption of the activity, we note a lack of knowledge of the different actors on this circuit: physician, nurses, fellows, patients himself.
The objective of the study is to reinforce the understanding and safety of the FMT circuit in a university hospital after the evaluation of the knowledge of the different actors.

What was done?

Implementation of a document to represent the circuit of fecal microbiota transplantation (FMT) in a French university hospital.

How was it done?

In this context, two questionnaires containing less than five questions on the functioning of the circuit were carried out with the nurse coordinators (NC) and the interns of the hepato-gastrology department. Subsequently, a document was drafted in consultation with the referring physician, the head of department and the pharmaceutical team to represent the FMT circuit.

What has been achieved?

With regard to the questionnaires, we obtained six answers from the NC, with 42% correct answers, 25% partial answers and 33% incorrect answers, and then six answers from the residents, with 20% correct answers, 7% partial answers and 77% incorrect answers.
These questions made it possible to draw up a diagram adapted to A4 format intended for all the actors in the circuit. It defines the different missions of all the actors with the corresponding deadlines and associated procedures.
In order to improve information, two interventions were carried out by the pharmacy: a staff meeting dedicated to the management of CD infections with the interns, co-hosted with the referring physician, and a presentation of the circuit to the NC.

What next?

Finally, this study made it possible to reinforce the safety of the FMT activity for the patient and to improve the management of the circuit for the various health professionals involved in this specialized therapy.

Author(s)

Dearbhla Murphy, Mariosa Kieran, Jennifer Brown

Why was it done?

The Emergency Department (ED) at our institution is one of the busiest in Ireland. In 2019, there over 84,000 attendances. The ED CPS is multifaceted and involves clinical review of prescribed drugs, consultation with medical and nursing colleagues to ensure safe, effective and rational prescribing, drug supply and Medicines Reconciliation (MR). In order to meet patient requirements during the COVID19 pandemic, the ED was re-configured. The departmental changes necessitated realignment of the CPS to ensure evolving institutional requirements were being met while maintaining service provision.

What was done?

• ED Stock lists were reviewed and modified to ensure prompt availability of COVID19 treatments.
• Drug lists were devised for new ED zones to ensure availability of emergency and antidote medicines on a 24/7 basis.
• ED requirements for COVID critical medicines e.g. neuromuscular blockers, propofol, midazolam and antivirals were implemented in response to emerging evidence.
• Appropriate drug and fluid storage locations were reviewed in line with legislative requirements.
• Pharmacy technician top-ups were modified and standing orders introduced.
• Technician staff received Personal Protective Equipment (PPE) training to facilitate topping-up of drug presses in high-risk patient-facing areas.
• Access to critical care and COVID19 Respiratory Infection treatment protocols was expanded to ensure point of care access
• All associated SOPs were updated
• CPS provision was reviewed, changes introduced include:
1. fixed zone staffing allocations to reduce cross-contamination of staff
2. guidance on Infection Prevention and Control measures for completing MR patient interviews
3. electronic transfer of Clinical Pharmacist handover to ward based pharmacists

How was it done?

• A multidisciplinary team (MDT) of stakeholders was formed of Nursing Management, ED Consultants and the Pharmacy Department.
• The ED pharmacist coordinated the Pharmacy review.
• The procedures and policies governing CPS provision and ED drug stock holdings, storage and availability were reviewed and adapted.
• The MDT supported roll out of the changes in practice through communication and staff training.

What has been achieved?

Continuity of the CPS provision to the ED during COVID19 pandemic was ensured.

What next?

Through this review, the multidisciplinary ED team collaborated to successfully review CPS provision to adapt for the unique and evolving clinical needs of patients during the COVID19 pandemic. This ensured the safe delivery of a high quality CPS and continuity of drug supply.

Why was it done?

Long waiting times and delays in patients leaving ED increase the risk for missed doses. Medication reviews and analysing incident reports identified missed doses as a patient safety issue where the strategies implemented aimed to improve this.

What was done?

Reducing missed doses and improving patient safety was addressed as follows:
 Integrated pharmacy service was established
 Audit completed
 Education model developed
 Stock list reviewed

How was it done?

Integrated pharmacy service:
-Outlined the role of the pharmacy team in ED.
-Pharmacist medication review service established which identified medication incidents particularly missed doses.
-Pharmacy technician role expanded: Reviewed patient charts, identified issues, collaborated with the ED team, and dispensed medication in medication
transfer bags.
-Implemented medication transfer service: Individual patient medication transfer bags were sent from ED to the transfer ward ensuring timely availability
of medication during transitions of care.

Data collection and analysis:
-Quantified missed doses and reviewed the percentage of these which were time-critical. Time-critical medications are medications where timely
administration is crucial to prevent patient harm.

Education model:
-Developed and implemented a pharmacy technician training programme: This ensured an optimal medication management service.
-A local list of time-critical medication was agreed upon. A poster was developed and erected in ED to highlight time-critical medication.
-Structured and targeted multi-disciplinary education was provided on time-critical medication and the impact of missed doses.

Stock list modified so medication was immediately available in ED. Capacity in the automated dispensing unit (ADU) was an obstacle so the ADU was reconfigured to overcome this.

What has been achieved?

 A clinical pharmacy service was established which reduced medication errors.
 Missed doses decreased by 75%.
 Time-critical medications are readily available.
 Medication transfer bags ensured timely availability of medication during transitions of care.
 Education model implemented which improved patient safety.

What next?

 Continue the integrated pharmacy service in ED.
 Missed doses will be assessed through point prevalence surveys, medication reviews, and incident reports.
 Extend the education model to other areas of the hospital and apply learning.
 This initiative can be adapted to other hospital settings.