Implementation of a sequential antibiotic therapy programme in a third-level hospital
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European Statement
Clinical Pharmacy Services
Author(s)
Ana Concepción Sánchez Cerviño, Jorge Coca Crespo, Maria Rivera Ruiz, Juan Ignacio Alcaraz López, Adrián López Fernández, Elena Pérez García, Bárbara Ubeda Ruiz, Amelia Sánchez Guerrero
Why was it done?
Sequential therapy, or switch therapy, consists of an early conversion from intravenous to oral (PO) treatment, without compromising the therapeutic effectiveness. In advantage, PO in selected cases, avoids intravenous associated risks, it is more comfortable to patients and represents an important economic saving.
The aim of the GPI was to implement a daily program that allows the pharmacist to identify the patients that would benefit from the AST.
What was done?
Implementation of a program of antibiotic sequential therapy (AST) and evaluate the outcome of the pharmaceutical recommendations carried out in a third-level hospital.
How was it done?
A database was created to select the active antibiotic prescriptions with more than 72 hours duration, susceptible to AST: metronidazole, clindamycin, levofloxacin, ciprofloxacin and linezolid.
Patients clinical criteria for initiating AST were established as:
• Temperature ≤ 37 ºC
• Systolic blood pressure ≥ 90 mmHg
• Heart rate < 100 bpm
• Respiratory rate < 24 rpm
• Oxygen saturation ≥ 90%
• Capacity for oral intake
Once the patients were identified, the pharmacist communicated the recommendation to the doctor in charge, and worked together to make a final decision.
Due to the high burden of care, the follow-up of patients who could not be substituted to PO in the first 72 hours was lost.
What has been achieved?
From October 2022 to March 2023, 453 patients on intravenous antibiotic treatment were reviewed. The mean age was 65.7 ± 20.9, and 57.4% of the patients were men.
47 patients were selected as they met the established criteria.
All the antibiotics presented a similar percentage of recommendation with a mean of 19.2% ± 6.3. Of this percentage, 59.6% of the patients were switched to oral antibiotics. Stands out linezolid, with a 83.3% of acceptance.
Lower respiratory tract infections were the most prevalent, representing 51.6% of the total. However, only 11 patients (5.1%) were suggested for AST due to the frequent use of nasal spectacles or oxygen therapy, a criterion that excludes AST
What next?
The high number of accepted recommendations shows the importance of implementing an AST programme in order to optimize antimicrobial treatment, and this initiative could be easily implemented to all Pharmacy Services.
Rethinking pharmacy and therapeutics committee procedures to achieve the efficiency required to overcome hospital complexity
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Sara Rodrigues, Sofia Pinheiro, Vandewalle Björn, Paulo Martins, Sofia Ferreira, Paulo Pereria, Jorge Félix
Why was it done?
Shared decision-making between pharmacists and physicians is key to PTC functioning and efficiency. Responsibilities include managing policies and procedures for appropriate use of high quality and cost-effective health technologies at hospitals. PTC performance is paramount to overall hospital efficiency.
What was done?
This project seeks to assess and redesign (optimize) existing Pharmacy and Therapeutics Committees (PTC) procedures within a University Hospital Centre (UHC – six public hospitals). The goal is to enable sound decision-making that significantly contributes to UHC key performance indicators, all while ensuring timely patient access to effective medication.
How was it done?
The project comprises four phases: (1) gathering feedback from stakeholders (PTC members; hospital service/pharmaceutical department directors) regarding their current involvement in PTC information flows, procedures, and decision-making; (2) developing a value-based criteria-matrix, across stakeholders, in a multiple-criteria decision analysis context, to guide future PTC decision-making; (3) rethinking PTC procedures and information flows; (4) assessing the effectiveness of the redesigned PTC model after 12 months. First phase included: a Likert-scale based survey1 for PTC members to evaluate their involvement in activities described in the internal PTC regulation, and a semi-structured interview-based survey2 for all stakeholders to characterize existing information flows and PTC mediated decision-making processes.
What has been achieved?
First phase: eight of 10 PTC members participated in survey1. Activities with 100% engagement of PTC members: prescription reviews; coordination with National PTC; monitoring of medicine utilization, antibiotics resistance and safety; advise the UHC management board. Activities with major non-engagement: monitoring/reporting of complementary diagnostics prescription (87.5%); medication therapy management programs (62.5%); National pharmacovigilance system activities (62.5%); therapy cost assessment (50%). In survey2 (n=14) authorization process for medicines utilization was accurately characterized, clearly identifying responsibilities for all clinical and pharmaceutical departments. Heterogeneity exists between urgent and non-urgent utilization requests. PTC members and pharmacy departments were more likely to use electronic platforms than clinical departments.
What next?
Next phases are under way to better support current competencies, information flows, procedures, and the shared decision-making processes offering an opportunity to rethink the PTC procedures in the University Hospital Centre and leverage efficiency over hospital complexity.
Evaluation and optimisation of the medication in patients with ileostomy
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
STEFANIE HEHENBERGER, IRENE LAGOJA, SANDRA BIELITZ-HOLZER
Why was it done?
Creation of a stoma means change in secretion, intestinal motility and absorption. Depending on localisation, this has also consequences for the absorption of drugs or certain drug forms. Data on absorption of drugs in ostomy patients are rare, but as most drugs are absorbed in the small intestine, ileostomy patients may more likely experience difficulty in absorbing and, therefore, gaining maximum benefit from oral medications.
What was done?
As part of a project, it was evaluated whether and which drug-related problems (DRPs) occur in stoma patients and, if so, measures for optimising drug therapy were proposed.
Relevant drug data (tmax, site of absorption, etc.) were collected and systematised in tabular form and the need for further pharmaceutical interventions was surveyed.
How was it done?
Over a period of 21 weeks, medication of Ileostomy patients (new created and pre-existing) hospitalised in various wards was screened.
A Level 3 medication analysis was performed, and the medication was then analysed with regard to possible stoma-specific DRPs.
All DRPs and pharmaceutical interventions were categorised and documented, and the identified DRPs brought to the attention of the patient’s medical team for review/ discussion in written form and/or personally.
What has been achieved?
Seventy-nine DRPs were identified in 15 medication reviews, of which 49 (62%) were classified as stoma associated DRPs. The pharmaceutical interventions were categorised, most common recommendations were monitoring (18) and change of the medication form (15). Acceptance of the interventions was also recorded (82%). Since a HOS (High output stoma) occurred frequently, an escalation scheme for the therapy of liquid stool and/or stool volume ≥1500ml/day was established. Finally, an interdisciplinary cooperation taking into account the complex patient factors could successfully be established.
What next?
Due to these results it can be assumed that ileostomy patients benefit greatly from pharmaceutical interventions, and that clinical-pharmaceutical care of ileostomy patients contributes to the drug therapy safety of this patient group and is therefore now being continued and incorporated into everyday clinical practice. In addition, further projects such as the creation of a standard operating procedure (SOP) for the interdisciplinary care of ileostomy patients are in progress.
Development of a new method for risk assessment related to management of clinical trials in hospital pharmacy: classification of protocols by risk index (ρ) and development of strategies for errors’ minimization
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Giulia CANCELLIERI, Piera POLIDORI
Why was it done?
Hospital pharmacist provides all management of investigational medical product(IMP), i.e. its conservation, distribution, return and destruction. However, each clinical trial involves different methods of managing the drug: this can mislead the pharmacist who has to manage multiple trials at the same time. With the aim of minimizing errors that may arise from the simultaneous management of different clinical trials, we have developed a method to classify clinical protocols by “risk index”.
What was done?
With the aim of minimizing errors resulting from management of clinical trials in hospital pharmacy, we have developed a method to classify experimental protocols into low-moderate-high risk(risk index). For each of these categories, standard procedures were then outlined in order to minimize the occurrence of any errors.
How was it done?
In order to determine risk index(ρ) we have identified all risks related to IMP’s management: pharmacological risk(φ), dependent on pharmacological characteristics of IMP; technological risk(α), if drug should be compounding; risk related to number of patients enrolled(np); risk inherent to the protocol(π), i.e. whether protocol involves placebo, or randomization, etc. These risks were then related through the formula created by us, ρ=φ+(α*np)+π: protocols are defined low-risk if ρ<50, moderate-risk if 51<ρ151. For each risk index, standard procedures were outlined in order to minimize risks, i.e.(for high-risk) inclusion of at least four pharmacists in “Delegation of Responsibilities Log”; scheduling monthly meetings with trial’s Monitor; dispensing of IMP with supervision by at least two pharmacists; etc.
What has been achieved?
We applied this method to 45 active trials in our hospital. For 3/45(6,7%) protocols, φ>75 because IMPs are carcinogenic; instead, 26/45(57,8%) protocols, involve IMP’s compounding; finally 29/45(64,4%) protocols are randomized and 14/29(48,3%) of these involve use of placebo. By applying aforementioned formula, we found that 3/45(6,7%) protocols are low-risk, 32/45(71,1%) moderate-risk, 10/45(22,2%) high-risk. For these 10, standard procedures were applied, to improve the safety of patients enrolled in a clinical trial.
What next?
We promote use of this method in other clinical centers, because we believe it can be a valid tool for risk minimization. Finally, we hope that we will receive numerous feedback from these centers to further improve the proposed method.
Analysis of antibiotic prescription over 4 months, antimicrobial stewardship team project
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Carlos José Cortés Sánchez, Josefina Giménez Castellanos, Mónica Abdilla Bonías, Arantxa Valdivia Piqueres, José María Gómez Portolés, Irene Toledo Guasp, Eva García Cortés
Why was it done?
Proper use of antimicrobials is essential to ensure their efficacy and minimize the emergence of resistance. The evaluation of antibiotic prescription in a district hospital can provide information about clinical practice, adherence to local protocols, and the possibility of addressing antimicrobial resistance issues.
What was done?
Review the appropriateness of antibiotic prescription according to local guidelines and protocols.
How was it done?
This is 4-month prospective observational study(May to August 2023) in a district hospital. A daily list of admitted patients on antibiotic treatment was obtained through OrionClinic® electronic prescription. Each patient was reviewed and discussed for appropriateness with antimicrobial stewardship team in a Microsoft-TEAMS© chat. The following data were recorded: registration date, patient identification, hospitalization unit, microbiological culture, treatment modality (prophylaxis, empirical, or targeted) and appropriateness using a Microsoft FORMS©.
Descriptive analysis expressed as number and percentage and relationships derived from registration: percentage of patients by hospitalization unit, treatment modality, and appropriateness. Percentage of patients on empirical treatment with microbiological culture. And appropriateness according to treatment modality.
What has been achieved?
A total of 172 patients were analysed, of which 83(48.25%) were surgical patients (orthopaedic surgery, general surgery, urology, gynaecology, otolaryngology), 64(37.2%) are from internal medicine,MIN, 17(9.9%) from intensive care unit,ICU, and 8(4.7%) from paediatrics,PED. Of the total of patients, 95(55.2%) had requested a microbiological culture. About 52(30.2%) patients were on prophylactic treatment, 103(59.9%) empirically, and 17(9.9%) on targeted treatment. In conclusion, 119(69.2%) antibiotic treatments were appropriate (prophylactic 26/50%, empiric 80/77.67% and targeted treatment 13/76.5%).
Breaking-down data by hospitalization unit and treatment, of the 83 surgical (49 prophylactic, 28 empirical, and 6 targeted) 47(56.6%) were appropriate. Among the 64 MIN patients(1 prophylactic, 56 empirical, and 7 targeted), 54(84.4%) were appropriate. In ICU of 17 patients(2 prophylactic, 12 empirical, and 3 targeted), 11(64.7%) were appropriate. In PED of 8 patients(7 empirical and 1 targeted), 7(87.5%) were appropriate. Of the total of patients on empirical treatment(103), in 28(27.2%) there isn’t microbiological sample.
What next?
This is a preliminary analysis of our hospital’s situation in order to assess where interventions are needed for those patients who are not appropriate. It also helps us identify the hospitalisation units in which it is more necessary to implement strategic non-imposing measures to improve antibiotic prescription.
Improving the management of asthma and COPD by educating the patient on the proper use of inhaler devices
European Statement
Clinical Pharmacy Services
Author(s)
Greta DUSABE, Jonathan DE GREGORI, Teo TODESCO, Vanessa GOMES, Hélène FEYEUX, Marine AGULLO, Cyril BORONAD
Why was it done?
Chronic Obstructive Pulmonary Disease (COPD) and asthma represent a significant public health issue. Medications are administered using inhaler devices (ID) that require prior demonstration to ensure their proper use. Incorrect usage of inhaler devices might have a major influence on the clinical effectiveness of the delivered drug.
What was done?
The goal of our study was to detect potential errors in the manipulation of inhaler devices (ID) and to provide patients with appropriate information on their correct use in order to improve medication management.
How was it done?
For this study, every hospitalised adult patient with an ongoing treatment with ID underwent a pharmaceutical interview during their hospitalisation.
This interview was done using a questionnaire assessing the patient’s knowledge of their medications and a 12-items evaluation grid covering every step of proper inhalation technique.
What has been achieved?
Between June and August 2023, 27 patients were interviewed: the average age was 73 years. 34 ID manipulations were observed. Dry powder inhalers were the most prescribed DIs (68%), followed by pressurized metered dose inhalers (23%) and soft mist inhaler (9%). For 10 DIs (29%), no explanation was given to the patient. Furthermore, inhaler technique instructions were provided by a pulmonologist (65%), general practitioner (23%), pharmacist (4%), nurse (4%) and therapeutic education program (4%). The interviews revealed that 71% of patients were not familiar with the prescribed molecules or their mechanism of action. Out of the 34 DI manipulations, only 15% were performed perfectly, and 27% were not executed properly. The steps of deep exhalation before inhalation and breath-holding after inhalation were not performed in 70% and 62% of observations, respectively. Finally, 50% of patients did not rinse their mouths after using inhaled corticosteroids.
What next?
This study has highlighted the improper use of DIs, which can lead to a loss of therapeutic effectiveness. Therefore, we have developed 9 information booklets on the correct use of the DIs that describe different handling procedures for proper inhalation. These booklets are provided at the end of the interview. Educating patients on the proper use of these inhalation devices during the initial prescription or dispensing should lead to an overall improvement in patient care.
Design, implementation and impact on patient safety of a mobile application for patients on antiretroviral therapy
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Esther Chamorro de Vega, Carmen Rodriguez Gonzalez, Belen Mayo Canaleja, María Pilar Montero Anton, Sergio Herrera Bermejo, Rosa Romero Jimenez, Vicente Escudero Vilaplana, Roberto Collado Borrell, Ana Herranz Alonso, María Sanjurjo Sáez
Why was it done?
The profile of patients receiving antiretroviral therapy (ART) has changed. Patients are more active, autonomous and have greater information and communication needs.
Mobile health, especially apps, can help to healthcare professionals to optimize pharmacotherapeutic follow-up and provide patients greater autonomy facilitating communication with healthcare professionals and contributing to the humanization of their care.
Through this application we seek to achieve the following objectives:
– Allow patients to participate in their illness and/or treatment, promoting their compliance and safety and communication with the healthcare professional.
– Strengthen pharmacotherapeutic monitoring of patients receiving ART, avoiding visits to the emergency room and hospital consultations.
– Generate pioneering evidence on the impact of mobile applications on the pharmacotherapeutic monitoring of patients on ART.
What was done?
FarMCuida® is a mobile application designed for a closer and better pharmacotherapeutic monitorization of patients on antiretroviral therapy (ART). Through this app the patient can actively participate in his or her disease and treatment.
How was it done?
A multidisciplinary group was created to design and develop an app called FarMCuida® for patients on ART in a tertiary hospital. Once the app was designed and developed, we offered the app to patients starting or undergoing ART. Identification and inclusion of candidate patients was performed in the Pharmaceutical Care Consultation of the Pharmacy Service. The pharmacists responsible for the Infectious Diseases area performed real-time pharmacotherapeutic follow-up of the patients.
Records of adverse effect (AE) and Safety-related messages received (Adverse effects, interactions, drug administration) can be analyzed. All data can be exported from FarmCuida®. Informed consent is requested from all the patients included.
What has been achieved?
FarMCuida® was designed as a digital health mobile application that allows our patients to participate in their disease and/or treatment, promoting treatment safety, as well as making available a source of information and bidirectional communication, in real-time, between patients and healthcare professionals.
During a period of 13 months, a total of 152 patients were included in FarMCuida®. Seventy-two percent of the patients were diagnosed with HIV infection while 27.6% of them were included in the HIV pre-exposure prophylaxis programme.
In AE module, 58 adverse events (AEs) were registered. Twenty-two percent of the patients registered at least one AE.
Thirty-two percent of patients used the Messages module to communicate with healthcare professionals.
One hundred and twenty-six telematic consultations were carried out. Two hundred and five messages were exchanged between the patient and the pharmacist.
Forty-three percent of the consultations corresponded to doubts about interactions: 66.7% interactions with other drugs, 28.5% with herbal products and 4.8% with vitamin supplements. Three type D interactions and one type X interaction were identified.
In addition, 11% of the consultations corresponded to doubts about the administration of ART while 5.2% were related to adverse effects experienced by the patient.
At least three visits to the emergency department were avoided, resulting in health care and economic savings for the health system.
What next?
Based on the limited studies on the impact of mobile applications on the pharmacotherapeutic follow-up of patients, the results obtained will allow us to generate evidence in this regard. It is worth highlighting the flexibility of FarMCuida® design, being easily adaptable to different pathologies and hospital centres.
Improving difficult-to-manage medication usage: a pharmacist led education programme for hepatitis delta virus (HDV) patients
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Sabrina Trivellato, Daniele Mengato, Francesca Venturini
Why was it done?
Bulevirtide, available in Italy since June 2023, is the sole approved drug for treating long-term HDV. It represents a precious clinical opportunity but its technical features make it a complex therapeutic regimen to handle. It is commercially available as a powder for injection that needs daily reconstitution before subcutaneous use, has strict storage requirements (+2/+8°C), and requires familiarity with needles and syringes. As home therapy, this is the responsibility of the patient, who will therefore need to be enrolled in a PEP to ensure compliance.
What was done?
A Patient Education Programme (PEP) was implemented to support patients diagnosed with hepatitis delta virus (HDV) being compliant to a complex therapeutic chronic regimen.
How was it done?
In July 2023, a specific pharmacist-led PEP (named “EXPLAIN”) was defined. It consists of two phases: education & training; follow-up & assistance. After clinical examination, patients were received by pharmacists and introduced to the therapy thanks to a simulation kit. Posology, storage conditions and special warnings were described and the drug together with the administration kit was delivered. During the follow-up phase the pharmacist was focused on proofing medication adherence, discussing with the patient about any problems or ADRs and drug refilling. Quality of Life (QoL, measured through EuroQoL5) was adopted as an effectiveness outcome. Evaluation feedback on the service was requested as well.
What has been achieved?
Up to September 2023, 15 patients, with a mean QoL starting score of 72,5/100±15, are assisted by the EXPLAIN program. 12 of them already accessed the follow-up phase. A single episode of medium gravity ADR was reported, but it did not affect therapy continuation. Globally, an excellent reported medication adherence (98.5% of doses taken) was registered and the educational support of the pharmacist was considered to be “essential on positively approaching the medication”.
What next?
QoL, adherence and feedback on the received service have to be proofed after 6, 9 and 12 months as well, together with a regular viral load detection to confirm referred compliance. Although the EXPLAIN program has just started, it represents a promising PEP model to be adopted in the case of complex therapies, where continuity is crucial to ensure effectiveness and safety.
Collaborative network between healthcare settings: hospital and community pharmacy
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Carmen Redondo Galán, Cristina Ortega Navarro, Ana de Lorenzo Pinto, Beatriz Torroba Sanz, Cecilia Martínez Fernández-Llamazares, Silvia Manrique Rodríguez, Álvaro Narrillos Moraza, Carmen Rodríguez González, Ana Herranz Alonso , María Sanjurjo Sáez
Why was it done?
Transitions of care put the patients at risk for medication error as a result of poor communication and information loss. Treatment beginnings, complex treatment and medication reconciliation errors are an important cause of morbidity and have a predominant role in chronic complex patients (CCP). In this sense, collaboration and effective communication between hospital and community pharmacy are considered essential elements to guarantee continuity of patient care, obtaining better health results in terms of safety, effectiveness and efficiency.
What was done?
Create and implement a collaborative network with direct communication between the Hospital Pharmacy Service of a tertiary hospital and the community pharmacies responsible for patient follow -up.
How was it done?
A multidisciplinary group of hospital pharmacists dedicated to different clinical areas was created: three pharmacists from the Emergency Department, two from the Paediatrics Department, one from the Neurology Department and one from the Outpatients area. They selected and contacted by telephone the 40 community pharmacies responsible for 25% of patient prescriptions in the area. Periodic meetings were scheduled and possible strategic lines of collaboration were shared. The following priority groups were identified: Group 1: CCP (paediatric patients and fragile elderly patients) and Group 2: patients treated in the hospital emergency department. We addressed logistical aspects (supplies and preparation of formulations), pharmacotherapeutic monitoring (adherence, adverse drug reactions and collaboration in the management of CCP). The main limitations were small population and short follow-up time.
What has been achieved?
From March 2023 to September 2023, the hospital Pharmacy Service has received 50 consultations on 45 patients from community pharmacies: 85% were classified as group 1 and 15% group 2. Pharmaceutical interventions were related to medical shortages (28%), reconciliation errors at discharge (22%), information about formulations (20%), information about new treatments (15%), prescribing errors (12%) and adverse drug reactions (3%). Community pharmacists appreciated accessibility and value of information provided by hospital pharmacists. 50% of patients avoided a hospital visit to solve their queries.
What next?
Our first results show the importance of pharmacist interventions with patients and other healthcare professionals.This collaborative network can be applicable to all services that work with community pharmacies to guarantee greater coordination and integration in the different healthcare settings.
User satisfaction assessment in outpatient pharmaceutical consultations: results and future perspectives
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Eva Gomez-Costa, Purificacion Cid-Silva, Juan Luis Hurtado-Bouza, Laura Caeiro-Martinez , Pablo Feijoo-Vilanova, Andrea Luaces-Rodriguez, Sandra Rotea-Salvo, Alejandro Martinez-Pradeda , Maria Isabel Martin-Herranz
Why was it done?
The purpose is to identify deficiencies and improvement areas in the outpatient consultation area for evaluation and proposal of possible solutions.
What was done?
Implementation of an user satisfaction evaluation system for outpatient consultations at the Pharmacy Service of a tertiary-level hospital and initial results assessment.
How was it done?
The system was put into operation in January 2023 through a QR code placed in each consultation room and in the waiting areas accessible to all patients. The survey allows for differentiation between the different pharmacy service centers in the hospital, patient-caregiver patient category, age group, and whether it was the first consultation or an appointment for treatment continuation. Users can rate aspects related to information, waiting time from the appointment time to receiving attention, the professionalism of the staff, respect for privacy, pharmaceutical information about the treatment, and the facilities. This rating can be classified into: very good, good, bad, very bad, except for the waiting time: reasonable or excessive. Final question is an overall assessment of the service from 0 to 10. Survey allows for comments or suggestions.
What has been achieved?
A total of 86 surveys were conducted between January and September 2023. The majority were from users of the pharmacy service in the main building of the university hospital complex (82.6%). 10.6% were from first-time appointment and were mainly patients who answered (67.4%). Age groups: 65 years (12.8%). Regarding the evaluation, the results were: information about appointments, 51.8% very good; waiting time from the appointment time to receiving attention, 59.3% reasonable; professionalism of the staff, 59.3% very good; respect for privacy, 59.3% very good; pharmaceutical information about the treatment, 51.2% very good. The evaluation of facilities where pharmaceutical care is provided to the patient were: 33.7% bad and 9.3% very bad. The average score for the overall assessment was 6.7 points.
What next?
The evaluation of the information obtained from the surveys will serve as a basis for implementing corrective measures and possible improvements. The progressive increase in the number of survey will facilitate the detection of new issues and allow us to track changes in user satisfaction over time.