Setting in situation of pharmaceutical validation of paediatric intensive care prescriptions by fifth year students: state of play and assessment
Pdf
European Statement
Education and Research
Author(s)
Omar HANAFIA, Pierre BERTAULT-PERES, Stéphane HONORE
Why was it done?
This internship was proposed to diversify the clinical pharmacy internship opportunities and to allow students to discover and understand paediatrics and intensive care, which are less covered in university courses. It will also be a proof of concept to develop this type of internship in other departments.
What was done?
We have proposed a new clinical pharmacy internship in immersion in paediatric intensive care to 5th year students. It is a hospital internship at the interface between the medical and pharmaceutical teams, the student is responsible for establishing a statement to analyse the drug management, its evaluation and improvement.
How was it done?
The clinical pharmacy student is a full-time employee, fully integrated into the medical team. Their day is divided into two parts: in the morning they attend the relief, the staff and the medical visit. In the afternoon, he/she takes over the patients, compiles the main medical, clinical and biological information in order to pharmaceutically prevalidate the medical prescriptions and propose pharmaceutical interventions (PI) to the pharmacist.
What has been achieved?
Since its opening, the position has been systematically chosen by the students, in 3 years 8 students have chosen it. After a training period of 1 month with the senior pharmacist, all students were able to perform the expected readings, prevalidation and PI. More than 78% of the PIs detected by the students were validated by the senior pharmacist and accepted by the physician.
What next?
This proof of concept shows that students are supportive of this type of initiative and are able to meet the high expectations of this internship.
Towards e-documentation of clinical pharmacist interventions
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Andrea Bor, Nóra Gyimesi, Eszter Erika Nagy
Why was it done?
Intervention-oriented classification systems are helpful tools to document the CPIs in a structured manner. Our aim was to develop a clinical pharmacy platform in the e-documentation system at our institution. This CPI data enables healthcare providers to track medication history, and to systematically analyse the effectiveness and the pharmacoeconomic benefits.
What was done?
A pilot survey was conducted on the traumatology wards to analyse and describe our clinical pharmacist interventions (CPI) based on severity and clinical relevance.
How was it done?
Three clinical pharmacists collected data on the changes of drug therapy at two 31-bed traumatology wards during pre- and postoperative period. We adopted the CPI classification system to our daily practices. This is challenging since the narrow time frame between patient admission and discharge often limits the opportunity to provide clinical pharmacy services. Raw data was previously screened and classified into 5 categories, drug related problems (DRP), clinical pharmacist intervention (CPI), significance (S), outcome (O) and acceptance (A).
What has been achieved?
We have established a data collection process, which allows us to record CPIs in our daily clinical environment in an efficient manner.
The most significant DRPs were incorrect dosage regimen (n=47), untreated indication (n=28), contraindication (n=25), excessive dose (n=19), subtherapeutic dose (n=17), drug interaction (n=15), no indication (n=11), experiencing adverse drug reaction (n=8), failure of drug administration due to shortages (n=5).
CPIs were divided into four groups:
1. Pharmacokinetic cause (dose adjustment, changes of drug dosage regimen, drug discontinuation, drug switch, etc.)
2. Pharmacodynamic cause (adding new drug, drug switch, – discontinuation, etc.),
3. Providing drug information (patient education, new drug, changes of administration route, etc.) and
4. Miscellaneous.
Significance were categorised as major (e.g. oral anticoagulant – LMWH switch, postoperative opioid use), moderate (e.g. loop diuretics – ion supplementation), minor.
Outcomes were therapeutic success, prevention of potential harm (e.g. adverse drug reaction) or cost saving.
73% of the interventions were accepted, the rest were rejected for the first time, but nearly half of them were admitted after minor modifications.
What next?
This CPI platform should be shared in the national digital health system.
Implementation of a clinical pharmaceutical service for ostomates
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Iris Summer, Marina Zakhari-Betros, Alice Poier, Christine Fegerl-Stadlober
Why was it done?
There had been reports from healthcare professionals of the presence of undigested tablets in ostomy pouches and reasonable doubts of adequate drug absorption. In addition, there were recurring inquiries from clinicians about drug related problems in ostomy-patients.
What was done?
Implementation of a clinical pharmaceutical service for patients with an intestinal ostomy following their stoma-surgery. In this service, oral drug therapy of patients with either ileostomy or colostomy was assessed to determine whether possible impairment of drug liberation or absorption could lead to malabsorption of drug therapy.
How was it done?
A project was conducted, where 30 ileostomy and colostomy patients were observed. Simultaneously, a literature review concerning all orally administered drugs of this patient collective was done. During the project time, two interviews were done with the patients. The first one was lead during hospitalisation whereas the second one was conducted within 4 weeks after hospital discharge. To standardise the interviews, two different questionnaires were developed. Medical status of the patient as well as pharmacokinetic properties of the drugs administered orally were thus assessed. It was evaluated whether there are any drugs which may feature any impaired drug liberation or absorption. In case of anomalies presented, such as undigested tablets found in the pouch, a plasma level measurement of the drug was done, if reasonable. In addition, the subjective perception of the patients was also taken into account, to measure whether malabsorption of drugs is recognised or not and if patients are aware of possible impairment of absorption.
What has been achieved?
A strategy was established to help healthcare professionals assess oral drug therapy in ostomates. In addition, awareness in healthcare professionals as well as patients was raised, concerning possible impaired drug liberation because of the use of inappropriate dosage drug form. Moreover, prevention of prospective drug related complications was also achieved.
What next?
1. Modification of our electronic medical record concerning automated pharmaceutical counselling.
2. Integration of a clinical pharmaceutical service within the ostomy care service of our hospital to provide better therapeutic outcome, especially when ostomy-related problems are presented.
3. Providing patient information leaflets to improve health literacy and patient satisfaction.
Implementation of automated alert system in high-alert medications in a network of hospitals
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
ROSALIA FERNANDEZ CABALLERO, ALMUDENA GARCÍA GARCÍA, MARTA HERNÁNDEZ SEGURADO, MARTA GÓMEZ PÉREZ, CARMEN MAYO LÓPEZ, ARACELI HENARES LÓPEZ, VIRGINIA COLLADOS ARROYO
Why was it done?
Our aim was to improve the safety of HAM appointed by ISMP Spain (Institute for Safe Medication Practices) specially restricting the prescription, creating automated alerts and advising in administration.
What was done?
The main objective was to identify and standardise in prescription and administration the high-alert medications (HAM), included in pharmacotherapeutic guide (PG) in a network of Spanish hospitals with about 1.330 beds.
How was it done?
Literature about HAM and recommended strategies was reviewed. We divided these drugs into two groups: HAM (heightened risk of causing significant patient harm when they are used in error) and very HAM (an error could cause death of patient). We identified both groups in electronic prescription system as follows:
– HAM: all prescribers are able to prescribe these drugs and they find yellow warning sign in left side of the drug in prescription screen and nursing electronic work plan for administration.
– Very HAM: these drugs need tracheal intubation or monitoring measures when they are administered to patients. Only prescribers in intensive care (ICU) and surgery units (SU) are able to prescribe them. For certain drugs, needed in medical hospitalisation units, all prescribers are able to prescribe them and they must confirm the prescription with confirmation message: “You are prescribing a HAM, an error could cause significant patient harm. Are you sure to continue?”. They find red warning sign in prescription screen and nursing electronic work plan.
Alerts were configured by systems team in our electronic prescription system.
What has been achieved?
We have identified 379 drugs as HAM. 324 drugs were configured with yellow warning sign.
Sixty-five drugs were identified as very HAM. Fifty-eight drugs were disabled to prescribe by all prescribers (only in ICU and SU).
Seven drugs were configured with red warning alert and confirmation message: dobutamine, isoprenaline, ketamine, labetalol, levosimendan, carboprost and methylergometrine.
What next?
As next phase of our project, we must develop a procedure to identify and create alerts in new drugs added to our PG as systematic risk assessment process. Moreover, we must evaluate the real impact of our alert system in prescribers and nurse team, to reduce alert fatigue. We will work in automatic reports with ignored alerts.
Introducing a clinical pharmacist in a paediatric palliative care unit: how to optimise complex drug regimens
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Daniele Mengato, Laura Camuffo, Anna Zanin, Fernando Baratiri, Barbara Roverato, Franca Benini, Francesca Venturini
Why was it done?
PPC patients are children with chronic or terminal illnesses requiring a high intensity of care. Because of their criticality, a strict clinical monitoring is needed, as well as personalised therapeutic strategies.
What was done?
The paediatric palliative care (PPC) unit aims to provide paediatric patients with the best possible care in the management of their disease to ensure the optimal quality of life. The pharmacist has joined the interdisciplinary team with the aim of improving drug management in both acute inpatient and chronic therapies.
How was it done?
From August 2021, the clinical pharmacist joined the PPC staff with the aim of improving medicine management. The pharmacist, primarily, took charge of the medication review process. Individual therapies were periodically reviewed by the multidisciplinary team on the basis of admissions and clinical changes. In addition, a formulary manual for healthcare professionals was drafted, with the description of the crushability of the most commonly used pharmaceutical forms in clinical practice by collecting and keeping up-to-date information from national and international handbooks.
What has been achieved?
Over the past eight months, initial drug reviews have been carried out for all 169 patients followed by the PPC unit, with collegial re-evaluations cyclically carried out for the most critical patients (15). These patients had at least 10 drugs to take each day and therefore assessments were made to simplify treatment regimens by providing 37 suggestions to physicians with the aim of reducing the risk of interactions and facilitating home therapy management. With regard to the handling of pharmaceutical forms, many galenic formulations have been proposed in order to reduce the crushing of solid forms as much as possible. Most of the suggestions were discussed and accepted by the medical team.
What next?
Clinical pharmacist’s intervention is crucial in the management of terminal or chronic therapies for critically ill patients. Next step will be the analysis of caregivers’ care burden, through a specific questionnaire that has already been validated, so as to improve the home management of this particular category of patients.
Implementation of a new work circuit in monography consultation of immune-mediated diseases of the pharmacy service
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
ALBA MARIA MARTINEZ SOTO, MARIA ONTENIENTE CANDELA, CARLES INIESTA NAVALON, PATRICIA ORTIZ FERNANDEZ, PILAR FERNANDEZ-VILLACAÑAS FERNANDEZ, ANABEL HERREROS HERNANDEZ, GEMMA MARTINEZ SOTO, CARMEN CABALLERO REQUEJO, MAYTE GIL CANDEL, ELENA URBIETA SANZ
Why was it done?
– Guide the pharmacist in the development of an individualised follow-up strategy for patient evaluating the frequency with which appointments should be established in the consultation of Pharmaceutical Care.
– Use the information from the specific questionnaires to detect possible failures therapeutic.
– Use the results obtained in the PROs to direct the recommendations pharmacotherapeutic to perform, which will be assessed in a multidisciplinary committee of immune-mediated diseases.
– Promote higher quality pharmaceutical care.
What was done?
Implementation of a circuit to improve pharmaceutical care and follow-up pharmacotherapeutic, incorporating the stratification of
patients according to the “Model of Stratification and Pharmaceutical Care for Diseases Immune-mediated Inflammatory Diseases” (MAPEX) and the use of Patient Reported Outcomes (PROs).
How was it done?
1. Selection of patients to include.
2. Design a database in Access for the collection of stratification data and PROs.
3. Selection of specific and generic PROs.
4. Stratification of active patients according to the MAPEX methodology at the beginning of the implantation and in patients who start during the follow-up period will be stratified at the baseline visit.
5. Establish a strategy for carrying out questionnaires (PROs) in consultation.
What has been achieved?
An Access database has been created that incorporates the blocks established by the MAPEX model with each of its variables broken down, allowing us to obtain the patient global score.
3 pathology-specific PROs have been selected (RAPID3 in rheumatoid arthritis, PSAID12 in Psoriatic Arthritis and BASDAI in Ankylosing Spondylitis) and a generic one, EuroQol-5D-5L.
The follow-up strategy based on the stratification was selected as the one proposed by the MAPEX model.
To carry out the PROs, those patients with arthropathies that are were under treatment with biological drugs.
It was decided to pass a specific PRO according to his pathology and the generic having a baseline intake, another at 16 weeks and another a year.
What next?
Design a study to measure the results in terms of quality of care obtained with this new circuit.
Pharmaceutical care for human immunodeficiency virus pre-exposure prophylaxis users
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
NURIA FERNANDEZ PIÑEIRO, CRISTINA GONZALEZ PEREZ, LIDIA YBAÑEZ GARCIA, NATALIA SANCHEZ-OCAÑA MARTÍN, JOSE MANUEL MARTINEZ SESMERO
Why was it done?
In our area all care for PrEP users was centralised in a specialised centre. Here, a multidisciplinary team made up of doctors, nurses and pharmacists integrated in a patient-centred care model. PrEP users are a potentially vulnerable population. Health education and motivation are provided in the PhC consultations to raise awareness about the use of medication and adherence to treatment, which are key to avoiding HIV infection. The use of sex-related drugs is a growing health problem in this population and has been associated with increased HIV transmission risk.
What was done?
Development and implementation of a monographic pharmaceutical care (PhC) consultation for human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) users.
How was it done?
On 20 January 2020, the PhC consultation was launched in a monographic STI care centre linked to a tertiary hospital.
– On the same day as the first medical appointment, the user attends a PhC appointment. In this unit the user receives the necessary information to properly take the medication. Possible interactions are reviewed, not only with medications, but also with natural medicine, sports supplements and drugs. All doubts are resolved and the medication is dispensed.
– Every 3 months medical follow-up is carried out and, in the PhC consultation, where not only possible adverse effects are reviewed, but also adherence and related problems are specially monitored. To increase the quality of care, active communication between all health personnel was ensured.
What has been achieved?
Until 30 September 2022, 3,460 initial visits and 13,349 follow-up visits have been made (411 of them through telepharmacy during the lockdown as a result of the global pandemic by SARS-CoV-2). From the users, 98.98% were men who have sex with men (MSM), 0.80% transgender women, 0.04% transgender men and 0.18% were women. 70.3% used sex-related drugs (Chemsex), with the most used substances being Popper (37.1%), mephedrone (28.2%) and gamma hydroxybutyrate (GHB) (24.6%).
What next?
In our experience, the role of hospital pharmacists as a reference health personnel for HIV-PrEP users has become clear, not only as an expert in medication. Given the prevalence of drug use in this population makes the health education that we hospital pharmacists can provide especially important.
Implementation of a screening circuit and prevention of infections in cancer patients treated with immune checkpoint inhibitors
Pdf
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
Pdf
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
Pdf
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.