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Author(s)

Vera Pires, Maria Teixeira, António Gouveia

Why was it done?

Cisplatin is a cytotoxic agent used in CT regimens in ST. (1) Nephrotoxicity is the main toxicity, and hydration is always indicated to prevent kidney damage. [1,2] In 2018, when we computerized the ST’s CT protocols, we verified the existence of variations in CH protocols. According to the bibliography, this lack of standardization could lead to sub-optimal treatment of patients, errors and unnecessary use of resources. [1,3] Thus, it was necessary to develop a standardized hydration protocol designed by pharmacists with the collaboration of oncologists.

What was done?

Standardize the cisplatin-based hydration (CH) protocols used in the solid tumors (ST) chemotherapy (CT) regimens in adults in our institution.

How was it done?

Audit of CH protocols used in ST in adults in our institution and literature review to build a standardized evidence-based protocol.

What has been achieved?

We gathered 31 CT regimens with cisplatin. Verified the existence of variations in the volume of hydration (VH) before and after cisplatin, in the volumes of drug dilution, perfusion time, in the use of oral hydration (OH) and in ionic supplementation. We found that all of them were indicated to perform cisplatin only “if urine output >100ml/min”, use of mannitol before cisplatin and furosemide in SOS. Through the consulted bibliography, 4 regimens were made and implemented in 2019, according to the dosage of cisplatin: HC1< 40mg/m2 (Hday) and HC21000ml, and mannitol is only administered if cisplatin ≥60 mg/m2 (RCM). All protocols have magnesium and potassium supplementation.

What next?

Thus, despite the lack of consensus in the bibliography, a standardized protocol was created based on the evidence and clinical practice of our Institution. It is our intention to assess the impact of this intervention, from the perspective of the patient and the Institution.

Author(s)

François TISSERAND, Pierre MENAGER, Alexandre NAVID, Léa ROUSSET, Adeline BANNIER, Julie MORIO, Hélène PERRIER, Elsa JOUHANNEAU

Why was it done?

The geriatricians contacted the pharmacy to deliver training courses to the geriatric residents. This has enabled pharmacists to develop a close relationship with geriatricians to offer them clinical pharmacy activities in their ward. Geriatricians were familiar with clinical pharmacy, in particular the medication reconciliation, which is used to perform the former in other hospitals. Geriatricians are concerned with iatrogenic illness and therefore see medication reconciliation and pharmaceutical analysis as a relevant approach to clinical pharmacy.

What was done?

A successful model of partnership between Geriatrics and Pharmacy has been created and developed.

How was it done?

A first meeting was held between geriatricians and pharmacists. It was decided a pharmacy resident would be dedicated to a given geriatrician. This first resident’s objectives are to follow the medical rounds and to carry out medication reconciliations upon admission and discharge. Pharmaceutical support has enabled real-time validation for the prescription of the appropriate drugs. As the internship progressed, the resident became the privileged interlocutor for a Pharmacy-Unit relationship.

What has been achieved?

To date, 37 medication reconciliations were carried out, where the resident followed 2 medical rounds per week over 17 weeks. All unintentional discrepancies were corrected (n=13). Concerning the appropriateness of prescriptions, 16 inappropriate medications were stopped. During the medical rounds, 34% of the therapeutic problems (n=35) were related to inappropriate drug according to guidelines, 17% to dosing errors, 14% to drugs without indication. More than 50% of pharmaceutical interventions were judged capable of preventing harm that requires increased monitoring or treatment or lengthening of the hospital stay (63%). During this period, 54 questions were asked and discussed between the resident and the geriatrician to improve patient care. At the geriatricians’ request, two courses were organized about non mastered topics. On the ward, the resident acted as a go-between for a number of issues such as referencing medical devices, rearranging the storage of medicines or finding the right contact person for information activities.

What next?

What has been done needs to be continued and improved. A pharmacist-geriatrician cross-training should be implemented soon. New activities with pharmacist-geriatrician interactions are being created, such as day hospitalization for falls in the elderly population and a geriatric emergency unit.

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Why was it done?

Oncology patients are often elderly and multi-medicated, with many physicians involved in their management. Their treatments can therefore often be changed while chemotherapy have a high risk of drug’s interactions. However, in our center, the length of patient stays and pharmaceutical resources are incompatible with the systematic achievement of reconciliation during hospitalization. In addition, more and more patients are benefiting from oral chemotherapy, outside any hospitalization. Besides, hematologists already offered teleconsultations to some patients, for their comfort and because of the COVID-19 pandemic.

What was done?

A pharmaceutical teleconsultation is now offered to our hematology patients in order to make the comprehensive list of medications taken, including self-medication, herbal medicines and food supplements. The comparison with the usual treatment in the medical record allows to update the patient file and prepares a proactive reconciliation.

How was it done?

A comparison and tests of the different reconciliation tools were carried out. The Hospiville® platform was chosen, also allowing remote and secure communication with retail pharmacies. Moreover, communication devices have been installed, such as webcams, headphones and microphones. This equipment was financed by our Regional Health Agency.

What has been achieved?

An appointment is offered to the patients listed on the weekly hematology teleconsultation schedule. Their usual pharmacy’s contact details are then requested.
Information collected from the medical file and from the pharmacy are provided on Hospiville®, then completed during the interview by Teams®. The pharmacist lists the prescribed medications, assesses the patient’s compliance and analyzes the interactions between drugs or complementary medicines. If necessary, the referring hematologist is contacted to adjust the drug’s management. Afterwards, the report of the teleconsultation is added to the medical file (Elios®).

What next?

By carrying out the consultation from home, patients report being more exhaustive in the information they provide. They also appreciate the short time needed and the easiness of speaking in familiar surroundings.
Thanks to scheduled teleconsultation, pharmacists further secure the patient’s medication path without disrupting the pharmacy’s activity. This experience will be used for the experiment “ORAL THERAPIES – home monitoring of patients on oral cancer drugs” in the French context of Article 51.

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Author(s)

Eline Coene , Catharina Olsen, Mathijs Swaak, Freya Vaeyens , Frederik Hes , Stephane Steurbaut, Sonia Van Dooren , Pieter-Jan Cortoos

Why was it done?

Pharmacogenomics has a large potential to optimize individual patients’ both current and future drug therapies. In Belgian hospitals however, pharmacogenomics is still rarely used in clinical practice posing great opportunities for hospital pharmacies to explore this field and setting up new services.

What was done?

The Centre for Medical Genetics (CMG) of UZ Brussel, a 721-bed tertiary hospital in Brussels (Belgium), has been performing next-generation sequencing of mendeliomes for diagnostic purposes since 2016. Pharmacogenomic data is thus potentially available, but currently not further used. As hospital pharmacists, we wanted to explore the possibility of reporting pharmacogenomic information as ‘secondary findings’, in particular prevalence of actionable pharmacogenes and gene-drug interactions (GDIs) in our own population, and to determine required features and opportunities of a future pharmacogenomics project

How was it done?

Firstly, 14 pharmacogenes comprising 626 loci were selected based on available guidelines, clinical relevance and whether the gene was included in the mendeliome gene set. With the support of CMG, we then reviewed available data for patients with a mendeliome analysis between 01/03/2016 and 30/06/2020. To enable haplotype assignment, a Python script was developed displaying possible haplotypes with corresponding ‘matching score’ and ‘completeness score’. Where possible, phasing was done using pedigree information. Resulting phenotypes were finally further linked with medication histories, abstracted from patients’ electronic medical records in order to identify possible GDIs.

What has been achieved?

Pharmacogenomic data could be re-used for 536 individual patients, revealing that at least 76.9% had one or more actionable phenotype while 60 GDIs with varying relevance were found. CYP2C9 had the most actionable phenotypes (174/536) and was involved in 42 GDIs. However, not all phenotypes (e.g. copy-number variants) were detectable for CYP2C19 and CYP2D6 due to limitations of current mendeliome data and used platform.

What next?

Reusing genomic data has great potential and can be an ideal stepping-stone towards developing and implementing pharmacogenomics in other hospital pharmacies but requires a good interplay between pharmacists, geneticists and bio-informaticians. In our hospital this initiative has led to in-depth collaboration between pharmacy and medical genetics department focusing on validation and implementation of a pharmacogenomics-array coupled with implementation of a pharmacogenomics service, next to pharmacological use of whole-genome sequencing data.

Author(s)

Marie Guedon, Maëliss Laurent, Thibault Vallecillo, Catherine Mennesson, Mélanie Jennesson Lyver, Dominique Hettler, Céline Mongaret

Why was it done?

In March 2021, the “Agence Nationale de Sécurité du Médicament” initiated an experiment to evaluate the relevance and feasibility of the availability of MC as a narcotic drug, in France. In our hospital, we included children to treat drug-resistant epilepsy, and performed a dispensing process to secure the patient care pathway and strengthen collaboration between hospital pharmacists and primary care professional.

What was done?

The aim of this study is to secure the care pathway of patients included in a national experimentation of medical cannabis (MC) by developing pharmaceutical interviews. Thus, to optimize the continuity of patient care, a pharmaceutical report was developed, and addressed to the community pharmacists of the patient.

How was it done?

A working group was created including clinical pharmacists, a neuropediatrician and a coordination nurse. During medical consultations, pharmaceutical interviews were conducted and led to pharmaceutic reports, sent to the community pharmacies of the patients. In order to evaluate this report, a satisfaction survey was carried out.

What has been achieved?

During the first six months of the experimentation, three children were included. The clinical pharmacist team (two senior pharmacists and two pharmacy residents) performed ten dispensing processes. During the eight pharmaceutical interviews, four pharmaceutical interventions were performed. Firstly, the interaction between clobazam and MC (noticed in one patient) required a dosage adjustment. Then, the association between MC and hepatotoxic drugs (found in two patients) requires hepatic monitoring. A pharmacovigilance statement was also drafted to report side effects (digestive disorders). The satisfaction survey of community pharmacists showed that the transmitted information, mostly related to the medication review, was considered as useful for the community pharmacies of the patients. This data helped to guide the pharmaceutical interviews during their dispensing process.

What next?

Pharmaceutical interviews and their reports lead to secure the patient care pathway and improve the communication amongst health care professionals. Those measures provide an optimal case management and avoid therapeutic breakdown. Nevertheless, difficulties have been reported, mostly due to delay in the supply chain of the community pharmacies. Therefore, this system requires some adjustments before it can be applied on a larger scale. One of the suggestions is a provisional calendar of consultations and dispensations.

Author(s)

Elena Lee, Yue Feng Toh, Nathaniel Lim

Why was it done?

Older patients on polypharmacy are predisposed to drug related problems (DRPs). While MTM service with pharmacist involvement can reduce DRP occurrence, few have examined its impact on reducing unplanned readmissions.

What was done?

This study was designed to determine whether a pharmacist-provided medication therapy management (MTM) service can reduce unplanned readmissions through the comparison with patients receiving usual care.

How was it done?

A retrospective cohort study was conducted in Changi General Hospital. Patients present for MTM service from Jan 2016 to Dec 2019 were included in the intervention arm (n=96) while patients who attended specialist outpatient clinics were recruited as control (n=98). Index visits from the same patient within 6 months of an earlier visit were excluded. Primary outcome was the change of unplanned admission post and pre 6-month of index visit comparing intervention arm against control arm. Secondary outcomes were descriptive of DRPs identified, number of recommendations from pharmacists, types of interventions and the potential risks avoided. Primary outcome analysis was conducted with linear regression and adjusted for potential confounders.

What has been achieved?

MTM sessions resulted in the reduction of unplanned admission rate by 0.83 (95% CI: -1.31, -0.34), p=0.001, after adjusting for confounders. For patients with admission prior to the index visit, the intervention arm had statistically significant lower incidence of unplanned admission post and pre 6-month of index visit by 0.916 as compared to control group (p=0.018). There are higher number of DRPs (144 vs 2) and pharmacist recommendations (40 vs 2) were found in the intervention arm compared to control arm respectively. The most prevalent types of DRPs were ‘Non-adherence’ (80.6%), ‘Drug omission’ (5.6%), and ‘Inappropriate dose’ (2.8%). The most common potential risks avoided were increased cardiovascular risk, n=29 (22.1%), increased fall risk, n=18 (13.7%) and increased risk of fractures, n=17 (13.0%).

What next?

The study suggests that pharmacist-provided MTM service decreased unplanned readmission rate. It has improved medication safety and quality of care by identifying and resolving more DRPs.

Author(s)

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

Why was it done?

Increasing number of CT with IT, in different pathologies, with different tumor locations, contributes an increase in the complexity of drug compounding and procedures. Their preparation, administration and handling requirements differ from current therapies.

What was done?

Identification of critical points concerning intratumoral treatments (IT) preparation in patients with cancer included in clinical trials (CT).

How was it done?

Ongoing CT with IT in our unit were reviewed to identify critical points regarding prescription and preparation process. 14 trials with IT, 8 (57%) of which have ongoing patients were identified. Two of these trials are “first in human”. The critical points were:

• Nature of the IT: virus (4, 29%), nanoparticles (3, 21%), ribonucleic acid (2, 14%), cyclic dinucleotides (2, 14%), monosaccharides (1, 7%), phospholipids (1, 7%) and proteins (1,7%).Particularly, virus have special safety measures and transport conditions
• Dosing units: mcg (4, 29%), plaque-forming unit/mL (PFU/mL)(3, 21%), mL (3, 21%), mg (2 14%), ng (1, 7%), 50% Tissue Culture Infectious Dose (TCID50)(1, 7%).
•  Prior dilution before filling the syringe: 8 (57%) of our preparations require at least one prior dilution.
•  Drug volume to prepare according to the tumor size: 8 (57%) IT preparations depend on the tumor size.
•  Depending on the depth of the target tumor lesion (visceral or superficial), different size of needle is required. This is important because different priming volumes of the needles are necessary.

What has been achieved?

The whole information necessary for a complete prescription, validation and correct preparation goes further than information usually needed for current therapies such as chemotherapy. The results of the study of the critical points allow us to elaborate the standardized operational procedures (SOP) for each CT and IT.  These SOPs include the necessary information for a correct preparation for each IT, reducing risk of mistakes and achieving uniformity in the process.

What next?

These types of therapies represent a challenge, and pharmacists have an important role in developing new procedures. Communication between radiology, oncology and pharmacy departments in a multidisciplinary teamwork is essential. This information may be useful to other centers due to the lack of experience and SOPs to work with this type of therapy.

Author(s)

Ruth Borchers, Linda Krampe, Andreas Fischer, Christian Thomas, Holger Knoth

Why was it done?

The aim of this study was to identify the clinical pharmacy services where the integrating of pharmacy technicians have the biggest impact to avoid drug-related problems.

What was done?

In the field of clinical pharmacy services there are activities that are suitable for pharmacy technicians under the supervision of a pharmacist. At the university hospital in Dresden one full-time pharmacist and one half-time pharmacy technician (4h/d) are looking after 80 beds in the department of urology. The main tasks of the pharmacy technician are medication reconciliation as well as clinical prioritisation by using guidelines to identify patients who are at high risk of drug-related problems.

How was it done?

Since 2019 the pharmacy technician is recording the interventions in a categorical excel sheet, there are two documentation weeks per quarter. The categories are drug name, short description of the drug related problem, intervention, classification (dose-related problems, consultation of general practitioner, consultation of patient, electronic prescription, other drug-related problems after discussion with the pharmacist, drug substitution).

What has been achieved?

During 22 documentation weeks from 01/2019 till 09/2020 the pharmacy technician documented 468 interventions. The main interventions are drug substitution on admission considering local guidelines (n=181; 39%), consultation of the general practitioner because of identified discrepancies on the medicine lists (n=138; 29%) and consultation of patients because of identified discrepancies (n=78; 17%). Dose-related interventions and other drug-related problems are detected by the pharmacy technician and discussed with doctors under the supervision of the pharmacist (n=49; 10%).

What next?

Especially in the field of medication reconciliation trained pharmacy technicians can be suitable to prevent drug-related problems. The consultation of general practitioners and patients because of identified discrepancies on the medication lists are time-intensive and probably would not happen in the same way without integration of the pharmacy technician. The drug substitution in consideration of local guidelines and the preparation of the electronic prescription lead to fewer queries from nurses or doctors.
Further research should focus on the quality of pharmaceutical interventions conducted by pharmacy technicians under the supervision of pharmacists.

Author(s)

Sonja Guntschnig

Why was it done?

The aim of this good practice initiative (GPI) was to identify local resistance patterns, improve prescribing quality, reduce hospital costs, calculate antibiotic use data, track problem organisms, infection clusters and enable transfer chains tracing.

What was done?

With the introduction of a new antimicrobial stewardship (AMS) group into Tauernklinikum, Zell am See, a new informatics tool called HyBase® by epiNet AG was implemented to establish an interface linking microbiological results, consumption of antimicrobials, the hospital infections surveillance system “Krankenhaus-Infektions-Surveillance-System”(KISS) and the hospitals antimicrobial resistance data. AMS teams need suitable AMS surveillance systems to track intervention changes and measure results.

How was it done?

After purchasing release by the hospital management, HyBase needed an interface with several IT system providers, namely the internal microbiology laboratory (KISS software), System Application and Product in processing (SAP), and two external microbiology laboratories.

What has been achieved?

Antibiotic consumption figures were obtained retrospectively by calculating defined daily doses (DDD). This also gave insight into problematic use of certain antibiotics and indicated potential for antibiotic restriction.
Antimicrobial resistance patterns were displayed, which led to the introduction of infection control and AMS measures. Alert organism surveillance data was obtained and evaluated for different wards.

What next?

Learning from this implementation will enable changes in antimicrobial prescribing which will lead to improvements, both in healthcare quality and patient safety as well as a potential reduction in prescribing costs. Alert organism clusters will be detectable as will be transfer chains in the healthcare setting. It will also allow for the introduction of infection control agent stewardship for example by testing hand disinfection compliance or recording the spread of surface adherent organisms.
This GPI addresses the WHO antimicrobial resistance global action plan and local antimicrobial medicines concerns. It may prove useful for other healthcare settings and can be easily implemented to obtain data necessary for robust effective antimicrobial stewardship.

Author(s)

CRISTINA GONZALEZ PEREZ, LUCIA GALÁN DAVILA, MARTA ORTIZ PICA, ELENA GARCIA SUAREZ, MARIA MOLINERO MUÑOZ, LIDIA YBAÑEZ GARCIA, NATALIA SANCHE-OCAÑA MARTIN, MARIA DE LA TORRE ORTIZ, JAVIER CORAZON VILLANUEVA, JOSE MANUEL MARTINEZ SESMERO

Why was it done?

Our hospital is a reference in our community for this rare disease. Since patisiran was approved, we have treated 19 patients. Due to the high cost of patisiran and the few patients treated, it is necessary to optimize patient treatments in the most efficient way.

What was done?

Transthyretin (TTR) amyloidosis is a rare disease caused by mutations in the TTR gene. These mutations alter the normal function of TTR protein, creating slowly progressive condition characterized by the buildup of abnormal deposits of amyloid in body’s organs and tissues.
Patisiran is a TTR specific small interfering RNA (siRNA) formulation in lipid nanoparticles, which has been shown to substantially reduce the production of abnormal TTR in patients with hereditary amyloidosis TTR.
With this project we look for achieve the greatest possible savings from patisiran drug without affecting the patient’s efficacy.

How was it done?

We created a working group with neurology department, to define patient’s groups according to:
– Prescribed doses (doses per patient weight; 0.3 mg/kg).
– Preparation’s losses because of the filters
– Losses of the extraction process.
– Other individual conditions as posology or personal preferences.
Patients belonging to the same group have to administrate patisiran the same days.
As the patient’s weight can change along the time, we agree with doctors and nurses to weight the patients every six months to perform doses adjustments. Therefore, every six months we should regroup the patients to optimize the most.

What has been achieved?

These clusters have made possible to reduce wasting vials and therefore to permit significant savings. We estimate around 208.115 € savings/year.

What next?

With this practice we look for a more efficient and sustainable rational health system. The savings achieved can be used to treat other patients or promote new investigations. Also, it makes possible a better healthcare team performance, working together for a better attention, health quality, security, and treatments efficiency. Monitoring weights to adjust doses and closer follow-up of patients by the different members of the multidisciplinary team are examples of the achievements.