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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.

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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.

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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.

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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.

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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.

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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.

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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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Author(s)

Trine R. H. Andersen

Why was it done?

In Region Zealand, 1 of 5 regions in Denmark, clinical pharmacist services have been developed and implemented for the past decade. Especially in the acute wards, clinical pharmacists are an integrated part of the team when receiving, assessing and admitting patients to the hospital. As stated by the EAHP, “Clinical pharmacy services should continuously evolve to optimise patients’ outcomes” (EAHP statement 4.8), and a new approach was taken to further optimise the existing collaboration between the physicians and pharmacists on patients’ medication.

What was done?

The clinical pharmacy department of Region Zealand Hospital Pharmacy engaged a project with a senior year anthropology student. The anthropology student observed clinical pharmacists working with clinical pharmacist services in three acute wards. The observations on the collaboration of patients’ medication processes were disseminated to the pharmacists and physicians at the wards. This will aid in further strengthening of the collaboration and utilisation the healthcare professionals’ individual competencies in the hospital wards.

How was it done?

A senior year anthropology student was engaged to do objective observations of the pharmacists and physicians when collaborating in the acute wards. An anthropologist is trained to suppress subjective opinions and has no previous inception of the healthcare professionals’ work in the acute ward, and hence can do low biased observations. For 4 months the anthropologist made objective observations several times a week at each ward, and towards the end of the studies also supplemented the observations with individual interviews to further understand observed situations.

What has been achieved?

After the field observations and interviews, recurrent observation points were extracted from data and presented to the pharmacist and physicians in plenum. Discussions on the presented observations was found enlightening and strengthened the teamwork by better understanding the differences in the pharmacists’ and physicians’ responsibilities in the medication process respectively. Take home messages were visibility as well as accessibility of the pharmacist, and respect of each other’s contributions to the team.

What next?

The data will further be analysed and processed during the anthropology student’s final year and master’s thesis. The take home messages will be combined in a short introduction leaflet aimed for newly employed clinical pharmacists.

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Author(s)

Aina Oliver Noguera, Luis Pérez de Amezaga Tomáss, Margarita Nigorra Caro, Fernando Do Pazo Oubiña, Esther Falcó Ferrer, Teresa Fernández Rodriguez, Maria Fiorella Sarubbo, Antònia Obrador de Hevia, Montserrat Vilanova Boltó

Why was it done?

Treatment with fluoropyrimidine produces severe toxicity in about 30% of the patients. This toxicity has been related to a reduction in the activity of DPD, the rate-limiting enzyme for fluoropyrimidine catabolism. This is due to certain genetic variants of DPYD, the gene encoding DPD. For this reason, regulatory agencies such as the European Medicines Agency (EMA) recommend determining DPD deficiency in all patients who are candidates for treatment with fluoropyrimidines.

What was done?

Design of a protocol for the Implementation of dihydropyrimidine dehydrogenase (DPD) genotype tests in our hospital so that the results can be clinically interpreted by the pharmacists, and then used to guide physicians in the dosing of fluoropyrimidines (5-fluorouracil/capecitabine). The project was done with the collaboration of the Genetic and Genomic Laboratory (GGL) located in the reference hospital of our territory.

How was it done?

The elaboration of the protocol took place as follows, coordinated by the oncology pharmacist:
– Informatics. They created a formulary at the electronic prescription programme (HP-HCIS®) for the inclusion of the patients in the testing protocol.
– Oncologists and nursing service. They were trained in the implementation of this new determination, as well as in the procedure for obtaining and sending samples to the GGL.
– GGL. They conducted the DPYD genotype tests and report the results to the oncology pharmacist.
– Oncology pharmacist. They did the clinical interpretation of the result based on the following European Society for Medical Oncology (ESMO) recommendations for heterozygous DPYD variant allele carriers:
-DPYD*2A (rs3918290): dose reduction of 50%
-c.1679T>G (rs55886062): 50%
-c.2846A>T (rs67376798): 25%
-c.1236G>A/HapB3 (rs56038477): 25%

What has been achieved?

Since the implementation of the protocol, 73 determinations of DPYD polymorphisms have been performed (November 202 to August 2022). Three patients (4.1%) were found to be heterozygous DPYD gene variant carriers (two DPYD*2A and one c.2846A>T).
The average time for obtaining the results was 17.5 days. For this reason, in most cases the treatment was started before the result was obtained.

What next?

We are working on the implementation of a new fluorescence technique that will allow us to shorten the time of obtaining the genotype result.

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Author(s)

Cathrine Noergaard Peulicke, Michelle Lyndgaard Nielsen

Why was it done?

The process of building a new hospital has led to development and rethinking the drug concept. At the hospital we always have “the patient first” in mind. This is our codex. That is why we are changing the concept for delivery, dispensing and administration of medication. We wanted to ensure that the concept functioned from a patient safety perspective, patient flow perspective, patient involvement perspective, professional development perspective and perspective of a healthy operation. The vision is the right medication, from the right hand at the right time.

What was done?

At the new hospital, the medication logistics will undergo major changes. There will only be medication for acute use at the wards, the rest will be delivered ready-to-use from the main pharmacy or from a decentralised unit, called Pharmaservice. Here IV-solutions with short expiration are being reconstituted and oral solutions are dosed according to the prescription. Tablets and capsules are dispensed in the multi-dose robot at the main pharmacy. The multi-dose medication is equipped with a bar code which is scanned at administration and full electronic documentation is obtained. The majority of the medication will be dispensed daily for 24 hours and delivered in boxes for each patient to the wards.
In order to ease the transformation, we have built a mock up of a Pharmaservice unit where this set-up is enrolled to all inpatient wards in the hospital on the geriatric ward, children’s ward and gynaecology and obstetrics ward.

How was it done?

A steering group was founded and membered by managers from the involved wards including the hospital Pharmacy. Frequent meetings with the involved wards has been necessary to ensure competences and communication. Post-implementation we are closely evaluating the initiative.

What has been achieved?

Patient safety is in focus and with the multi-dose dispensing robot we have achieved full electronic documentation from the prescription, dispensing and administration process, and thereby have reached closed loop medication.

What next?

Having implemented the initiative on three wards, we are now working on enrolling this to the entire new hospital when it is ready in 2024. At the new hospital, we will have five Pharmaservice units servicing all inpatient wards.