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Development of a guide intravenous administration

European Statement

Clinical Pharmacy Services

Author(s)

Gregorio Romero Candel, Esther Domingo Chiva, Jose Marco del Rio, Marca Diaz Rangel, Wals Valladolid, Sergio Plata Paniagua, Nuria Maryinez Monteagudo

Why was it done?

Critically ill patients often require the administration of several intravenous drugs. Besides, we have many times limited intravenous accesses in which the administration of drugs and other intravenous compounds such as parenteral nutrition must be shared.
Because of that, it is very important to have drug administration guides standarizing every-day clinical practice.
This guide was developed in order to reduce the health care workers burden and promote patient’s safety.

What was done?

We developed an updated guide on direct intravenous administration of drugs for health care workers of both critical care and emergency departments.

How was it done?

A database with every intravenous drug that is included in the Pharmacotherapeutic Guide in our hospital was prepared, alphabetically organized by Active Pharmaceutical Ingredient (API). The following data were collected: API, tradename, available dosage forms and recommendations for direct intravenous administration.
For each API, a bibliographic research of information was conducted, among other hospital administration guides, manufacturer´s product information, drug databases (BOT plusR, Micromedex) and requests of information to the technical departments of the manufacturer.
In case of a discrepancy in the information, the guide with higher evidente or more recent was selected.
The antineoplastic drugs were not included in this guide because they are not used or prepared in critical care or emergency departments.

What has been achieved?

This guide promotes safe administration of drugs in critically ill patients, being a useful, accesible and easy-to-use tool for nurses.
Its elaboration allows us to standarize the direct intravenous drug administration, to inform every health care worker and make them aware about its importance. Besides, the Pharmacy Department actively participated in the process of safe drug administration in our hospital

What next?

We are still working on the same departments to improve safety in drug therapy in critically ill patients. Currently, improvement measures that are being developed are: new pharmacotherapeutic protocols specifically for this unit; drugs and drug-diluent compatibility guidelines and new training sessions.

Obtaining patient feedback via a forum group

European Statement

Clinical Pharmacy Services

Author(s)

Ishrat Saddiq Ali, Gemma Harris

Why was it done?

The idea behind setting up this group was inspired by passionate Pharmacy Team members who wanted to ensure that the Department was abiding by the Trust’s promises and standards for patient care, making sure that patients feel welcomed, cared for and in safe hands, and to raise the profile of the work carried out by the Hospital Pharmacy Team.

What was done?

In October 2014, the Pharmacy department set up a Pharmacy Patient Forum Group (PPFG).
The main aim of PPFG was to discuss ideas and share experiences from patients to support the Pharmacy Department, regarding implementing new changes to enhance patient safety and experience. This would support in delivering the Trust’s objectives for becoming best in class for patient experience.

How was it done?

Meetings are arranged approximately every 6 weeks and attended by:
• Trust Membership and Engagement Manager
• Pharmacy staff – Senior Pharmacist and Ward Based Services Technical Manager
• Trust members

Patient representatives were given a complementary tour of the Pharmacy Department where they could see the workforce in action and appreciate the workload of the team. The tour included:
• Dispensary
• Aseptic Unit
• Out of hours Medication Area
• And a visit to the Admissions ward where they saw the Ward Based Pharmacy team in action.

What has been achieved?

Several projects are being carried out simultaneously. The main project arose when patient representatives raised concerns about correctly identifying indications of medicines due to polypharmacy. We have designed a universal sticker images to enable patients to identify indications when faced with language barriers or vision problems. We have successfully developed a cardiology, indigestion/heartburn and pain specific sticker.
We have gained approval from other specialities regarding the images.
Another project focussed on tackling patients’ negative perceptions about discharge delays regarding medication. Patient representatives were invited to view the MEDI-365 automated dispensing machine which are utilised by Ward Based Clinical teams. This led to patient representatives viewing the pharmacy Prescription Tracking System (PTS) which is used to provide live information to all ward staff about pharmacy workload and track patients’ medication. The PTS has been further refined to produce a label which is attached to discharge medication detailing the time taken to process the prescription.
Patient representatives reported that they welcomed the opportunity to see a Pharmacy Department functioning within a busy District General Hospital

What next?

• We are looking to involve local primary schoolchildren/college students in the design of future images. This will aid in helping strengthen local community relations and raise awareness of the projects.
• We are currently working on producing a Discharge Leaflet explaining the Pharmacy Discharge Pathway.
• We find it extremely beneficial to meet via PPFG. We are keen to pursue with these meetings so we can work in collaboration on future initiatives to improve patient experience and safety

We have currently showcased our work in the following:
• Article published in Membership Connect Magazine in September 2015
• Article published in the PJ recently(http://www.pharmaceutical-journal.com/opinion/correspondence/obtaining-patient-feedback-via-a-forum-group/20201596.article)
• Presentation given to ‘Friends of Expert Patients Programme’ September 2016
• We have submitted an application to West Midlands Innovation Day to consider our work
• Article published in the Trust Connect Magazine in October 2016

A PHARMACIST IN THE MULTIDISCIPLINARY ONCOLOGY TEAM

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European Statement

Clinical Pharmacy Services

Author(s)

Ulrike Guger-Halper

Why was it done?

The pharmacy of the hospital supplies four hospitals with cytotoxic infusions. In the past it was found that the integration of a pharmacist in the oncology team brings benefits.

What was done?

Integration of a pharmacist in the oncology team

The aim was to evaluate the participation of a pharmacist in the multidisciplinary oncology team. The team consists of the clinical pharmacist, medical oncologists, residents, oncology nurses, dieticians, medical documentation assistent and a clinical psychologist.

How was it done?

Data were collected from May 2014 to September 2015.
All chemotherapy protocols were electronically prescribed in CATO® (computer aided therapy for oncology) and included cytotoxic drugs and concomitant medications.
In addition to production in the cytostatic unit the pharmacist participated in the daily morning meetings, the two-week tumor boards and bimonthly team meetings.
Pharmacist interventions (PI) took place during the meetings and were also communicated by phone and mails.

What has been achieved?

3335 cycles of chemotherapies were prescribed and 914 interventions were recorded.
CATO®-related PI (33,3%) were categorized in: literature research (4,7%), chemotherapy protocols (3,2%), dose selection (16,7%), treatment duration (1,4%), application/infusion time (0,9%) and others (6,4%).
Not CATO®-Related PI (66,7%) were categorized in: logistics (24,2%), patient-related (26%), drug-related (16,5%)
Under pharmaceutical participation: 15 guidelines, 1 abstract for a poster presentation, 27 work tools, 2 workshops, 2 publications, 1 lecture, 15 staff trainings, wipe samples in preparation

What next?

In this observational study we demonstrated the significant role of the clinical pharmacist as a part of the multidisciplinary oncology team. The supply by a pharmacist means to optimize treatment protocols and procedures and improving patient safety.
Medication errors occur despite electronic prescription of standardized protocols. Clinical pharmacists with special experience in oncology play an important role to identify errors in oncology.
A plausibility check by a pharmacist is still needed.

References: Sessions J. K. et al., Role of Oncology Clinical Pharmacists in Light of the Oncology Workforce Study, J Oncol Pract. 2010 Sep; 6(5): 270–272.

SEAMLESS PHARMACEUTICAL CARE OPTIMISING ANTICOAGULATION MANAGEMENT IN THE PERIOPERATIVE PERIOD

European Statement

Education and Research

Author(s)

F. Reidy, M. Duggan, A. Mathew, G. Duignan, S. Nasim, H. Ryder, B. Giblin, B. O’Connell, J. Corcoran

Why was it done?

The management of patients on oral anticoagulant drugs in the perioperative period has become confusing due to the introduction of:
– Newer oral anticoagulant and antiplatelet drugs
– Increased number of day case surgeries and early discharge, leading to lack of optimum care of patients, with anticoagulation and thrombophylaxis measures being undermanaged, resulting in prolonged hospital stays and cancellations of procedures.

What was done?

Following informal discussions with pre-assessment clinic (PAC) nursing staff, anaesthetists, pharmacists and surgeons, an evidence based management plan for thrombophylaxis and anticoagulation in the perioperative period for surgical patients was developed comprising of:

Thromboembolism risk assessment and bleeding risk stratification tool, to risk stratify all patients being admitted for surgery.

Prescribing guidelines on the management of anticoagulant drugs in the perioperative period.

Patient information leaflets on the management of anticoagulant drugs and thrombophylaxis measures pre and post procedure.

Preprocedure and discharge pharmaceutical plans to facilitate patients’ anticoagulation drugs to be managed effectively in the community.

How was it done?

Draft guidelines were disseminated to relevant staff and an opportunity was given for feedback over a period of 1 month. Following these recommendations, the guideline was introduced at the weekly surgical meeting. Information was then disseminated to the relevant departments.

One year later an audit demonstrated that these guidelines provided clarity with the decision making process regarding anticoagulation and thrombophylaxis, resulting in improved patient safety outcomes in the perioperative period. The need for educational training on the guidelines and simplification of the risk assessment tool was highlighted.

What has been achieved?

• Patients’ anticoagulation needs pre and post procedure can be managed with clear instructions in the perioperative period across the hospital/community interface.

What next?

The tool will be adapted to help with the decision making process regarding anticoagulation and thrombophylaxis for medical patients.
The complexities of perioperative anticoagulation are addressed in a simple way that the development of an App would benefit patient safety.

IMPLEMENTATION OF A SAFETY AND HEALTH PROGRAMME FOR THE MANAGEMENT OF PATIENTS WITH HEPATITIS C RECEIVING TREATMENT WITH DIRECT ACTING ANTIVIRAL AGENTS

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European Statement

Clinical Pharmacy Services

Author(s)

S. IBAÑEZ GARCIA, C.G. RODRIGUEZ-GONZALEZ, A. GIMENEZ-MANZORRO, E. CHAMORRO DE VEGA, R. COLLADO-BORELL, E. LOBATO-MATILLA, A. DE LORENZO-PINTO, M. TOVAR-POZO, A. HERRANZ-ALONSO, M. SANJURJO-SAEZ

Why was it done?

CHC affects approximately 3% of the world’s population. The development of well tolerated and effective AADs has changed the therapeutic landscape. These therapies have a high efficacy with a good safety profile. Numerous challenges in terms of patient education, monitoring, medication errors, drug interactions and adherence exist. Our National Health System launched a strategy plan for proper CHC management in April 2015, establishing, among other things, measures to optimise AAD use.

What was done?

We have developed a pharmaceutical care programme.

I. The following protocols were defined:
– A case selection and treatment guideline, following the recommendations from health authorities.
– A protocol for the management of drug interactions.
– A protocol with recommended dosages and administration techniques.
– A protocol with potential adverse drug events and recommendations about how to prevent and manage them.
– A protocol about clinical interview to ensure patient literacy and co-responsability.
– Patients information leaflets.

II. The pharmacy department was provided with:
– 3 full time pharmacists.
– 2 patient information offices.
– a queue management system.

III. Appointment scheduling:
Pharmacy visits were scheduled after the hepatologist/infectious disease specialist appointments every 28 days.

IV. The clinical interviews were documented in the electronic health record.

How was it done?

A multidisciplinary team was formed with two hepatologists, one infectious disease specialist, three clinical pharmacists and one nurse to:
– Address the key points associated with the safe and efficient use of AADs.
– Create a useful clinical guideline.
– Identify staffing and logistics needs.

What has been achieved?

No of patients included in the programme: 674
No of initial visits: 674
No of follow-up visits: 1750
No of patients attended/day: 19.9
No (%) adherent patients at the end of treatment: 412/412 (100%)
No of pharmacist interventions: 195
No (%) pharmacist interventions accepted: 194 (99%)
Average waiting time to be attended by the pharmacist: 15 min
No of queries made to the hospital pharmacist: 84
No of adverse drug events reported to the pharmacovigilance centre: 31
Cost savings (€): 121 194

What next?

This initiative provides a set of recommendations regarding CHC management and a support guide to standardise and guarantee high quality pharmaceutical care.

The next step is to develop pharmaceutical care programmes for the management of other pathologies following the same methodology that we have used for this initiative.

IMMPACT: A THERAPEUTIC EDUCATION PROGRAM TO SUPPORT SEAMLESS CARE FOR PATIENTS LIVING WITH CANCER

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European Statement

Clinical Pharmacy Services

Author(s)

A. Decottignies, D. Bouchoucha, S. Lévêque, S. Barthier, J.F. Morere, A. Marfaing, A. Rieutord

Why was it done?

Cancer has become a chronic disease. However, the impact of the disease and related treatments on patients’ everyday life remain poorly addressed all along the patient clinical pathway. The objective was to customise support to the patient to be able to better understand and control the disease and treatment consequences.

What was done?

An integrated care model based on a therapeutic education programme (TEP) was designed to better support patients living with cancer in their everyday life. The hospital pharmacy led the project, launched in October 2013 and implemented for patients in March 2015. It is called IMMPACT (impact of illness and medication in patients undergoing chemotherapy). This TEP was accredited by the National Authority (ref No ETP 13/30 in August 2013).

How was it done?

A transprofessional working group was formed. Our concern was to propose a smooth and safe transition from hospital to home. To do so, the hospital set up a partnership with the health network to facilitate seamless care. A prospective survey was conducted in October 2013 including 41 ambulatory patients. Three priority themes were identified: tiredness, haematological problems and digestive disorders management. According to the results, educational sessions have been collaboratively designed and implemented.

What has been achieved?

The patients group workshops began in January 2014. To date, 31 group workshops have been run. These group workshops are facilitated by trained healthcare professionals using educational tools such as Barrows Cards, mosaic characters or metaplan. 83 patients have already experienced this programme. Patient global satisfaction is >92%.

What next?

Given the success of this programme and to fulfil the growing expectations of patients, new sequences are being designed about pain, chemotherapy related neurotoxicity, socio-aesthetics and lymphoedema management as well as developing a serious game for the patient. Finally, IMMPACT extension to community pharmacists is being considered to further sustain patients empowerment and continuity of care.

BREAKING BARRIERS: MEDICATION SAFETY IN TRANSITIONS OF CARE

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European Statement

Clinical Pharmacy Services

Author(s)

M. Cabré Serres, T. Aguilella Vicente, E. Julián Avila, D. Rodríguez Cumplido, J.M. Pepió Vilaubí, M. Muñoz-García

Why was it done?

As a part of a multicentric medication reconciliation (MR) study in the fragile patient, one of the phases of the project included primary care reconciliation so we had to create alliances and enable effective communication channels between the two levels of care.

What was done?

During 2015, we started using direct messaging between hospital pharmacist (HP) and primary care physician. The messaging tool, which is available in SIRE and ECAP programs, allows you to send messages to all physicians caring for the patient. It also allows you to contact the usual pharmacy of the patient. Physicians receive messages automatically during the patient’s clinical course.

How was it done?

When patients were medically discharged, the HP performed MR. The HP contacted the next provider to inform them of changes in the medication list and safety alerts. When the patient visited the doctor, he already had the pharmacotherapy summary and pharmaceutical recommendations in the patient’s electronic clinical course. Afterwards, the HP assessed if the pharmaceutical interventions (PIs) had been accepted.

What has been achieved?

We started using the tool in January 2015. We performed 205 discharge reconciliations and have sent 143 messages. This would be 0.7 PIs/patient. PIs have been: 26.6% (n=38) remove medication, 21.0% (n=30) monitor treatment, 21.0% (n=30) increase adherence, 11.2% (n=16) modify dose, 8.4% (n=12) add medication, 6.3%(n=9) modify posology and 5.6% (n=8) replace medication. Finally, 72.7% (n=104) of PIs have been accepted and 27.3% (n=39) rejected. We can also analyse population characteristics and the drugs involved in the PIs.

What next?

We are breaking barriers between hospital and primary care with nexus of the HP, who has begun to be part of the medical team. We want to continue in this direction to improve the results of our PIs. We want to determine if our PIs improve health outcomes. Another current problem in the transition of care is hyperprescription treatments with proton pump inhibitors or benzodiazepines. A de-prescription programme could be the next step.

ELECTRONIC RECORDING OF MEDICATION RECONCILIATION AS A RELIABLE REFERENCE FOR MULTIDISCIPLINARY CARE

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European Statement

Clinical Pharmacy Services

Author(s)

C. Bilbao Gómez-Martino, M.I. Borrego Hernando, A. Santiago Pérez, M.P. Pacheco Ramos, A.E. Arenaza Peña, L. Zamora Barrios, E. Rodríguez del Río, J.C. Tallón Martínez, Á. Nieto Sánchez, M.L. Arias Fernández

Why was it done?

MR has been proven to reduce medication errors at admission. If there are no electronic records of PCM, the information obtained by MR usually gets lost and could lead to repetition of errors.

What was done?

We provided electronic updated reports of patients’ current medications (PCM) after performing medication reconciliation (MR) at admission, although the electronic medical record (EMR) is not yet developed in our hospital.

How was it done?

The procedure, designed in the framework of a pilot MR programme, was gradually implemented in three hospitalisation units: internal medicine, geriatrics and oncology.

In order to make the medication reconciliation reports (MRR) reliable, the pharmacist consulted primary care prescriptions and at least two other independent sources of information, such as: emergency department’s admission report, previous clinical reports, self-reported medication list or the medication itself, if possible. The information was confirmed by a standardised clinical interview. Medication discrepancies were clarified by specific closed ended questions. The rest of treatment was investigated by open ended questions.

MRR included current chronic medication, relevant medications administered on demand, herbal medicines used for therapeutic purposes and other relevant data (inappropriate medications, interactions, dysphagia, adherence). Sources of information were also detailed.

MRR were integrated within the electronic hospitalisation reports, which were easily accessible via the hospital intranet.

At discharge, printed copies of reports were handled to patients.

What has been achieved?

99 MRR were recorded. 751 PCM were registered and 183 MR errors (MRE) were detected.
We contribute to the ‘best possible medication history’ of patients. This initiative might have improved patient safety by reducing discharge and readmission MRE, although it has not yet been measured.
We enhanced the pharmacist’s role in the multidisciplinary team.

What next?

This model of electronic MRR could become a useful reference for healthcare professionals, until the EMR is implemented. The next aim is to register MRR and all pharmaceutical care information in the EMR to improve our patients’ healthcare.

IMPLEMENTATION OF A PHARMACY TECHNICIAN COORDINATED MEDICATION SUPPLY SERVICE IN A PAEDIATRIC ELECTIVE TREATMENT CENTRE

European Statement

Selection, Procurement and Distribution

Author(s)

H. Thoong

Why was it done?

PETC admits approximately 15 000 patients per year and is a high user of high cost drugs. Traditionally, a pharmacist provided a clinical and supply service with no technical support. Frequently, prescriptions were written late, dispensed items were lost and patients waited unnecessarily to receive treatment. Furthermore, patient non-attendance and medication re-supply due to misplacement of original dispensed items led to stockpiling of medicines.

What was done?

A pharmacy technician (PT) coordinated medication service was introduced onto the Paediatric Elective Treatment Centre (PETC) to decrease patient waiting time (PWT) and drug wastage.

How was it done?

Prior to admission, patients requiring medication were identified by a PT. If medication had been prescribed, this was transcribed onto a pharmacy order form. The prescription chart and order form were clinically checked by a pharmacist. If the drug had not been prescribed, prescribers were contacted. The medication was dispensed and delivered to the ward in advance. The PT ensured all required medication was readily available on the ward. Data on PWT, time to process medication orders, cost of unused drugs and number of items available prior to attendance were collected for a 6 month period.

What has been achieved?

Total cost savings achieved due to returned unused medication amounted to £82 074.

What next?

To extend the role of the PT in PETC. Therefore, the PT will undertake basic medication reconciliation, assessment of patients’ own drugs and notify the clinical pharmacist of patients requiring a full medication review.

DEVELOPMENT OF A 7 DAY CLINICAL PHARMACY SERVICE

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European Statement

Introductory Statements and Governance

Author(s)

S. Antoniou, M. Sullivan, P. Wright, J. Quinn

Why was it done?

The cardiac centre receives over 1800 acute admissions per year, with 20% of patients admitted on weekends. National reports highlight increased mortality at weekends, which has led to a call for the NHS to provide a consistent service throughout the week1. In accordance with the European statements of hospital pharmacy2, there was a need to ensure all prescriptions be reviewed and validated promptly on admission.

What was done?

Implementation of a 7 day clinical pharmacy service to a newly merged cardiac centre.

How was it done?

A successful business case for additional resources allowed for expansion of existing service to be delivered. This facilitated change in working hours for frontline staff, including provision of a shift system ensuring the EU working time directive3 was not exceeded. Expansion of the ward based pharmacy technicians’ role to include ward based dispensing led to timely access to medicines. An increase in the visibility of pharmacy staff at the ward level facilitated a patient facing clinical pharmacy service over the 7 days.

What has been achieved?

All new admissions and discharges are reviewed at weekends with visits to coronary and intensive care. Medicines reconciliation within 24 h is above 95%. 98% of discharge medication is supplied at ward level and 93% prepared prior to discharge prescription written. Feedback from patients, nursing and medical staff has been extremely positive.

What next?

The service is currently provided for patients admitted within the cardiac services. A review is underway to consider staffing requirements to implement the service across the whole site and the trust.