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LOCAL FORMULARY OF PALLIATIVE CARE IN THE ADULT PATIENT: A MULTIDISCIPLINARY APPROACH TO SYMPTOM RELIEF AND CONTINUITY OF CARE

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European Statement

Clinical Pharmacy Services

Author(s)

Francesca Baldi (1), Irene Bosoni (1), Sofia Filippini (1), Annamaria Valcavi (1), Gradellini Federica (1)
Alessia Rondini (3), Monica Salsi (3), Silvia Tanzi (2), Sara Alquati (2), Corrado Bacchi (3)
1. Pharmacy Department, Azienda USL-IRCCS, Reggio Emilia, Italy.
2. Palliative Care Unit, Azienda USL-IRCCS, Reggio Emilia, Italy.
3. Hospice Unit, Azienda USL-IRCCS, Reggio Emilia, Italy.

Why was it done?

Palliative care (PC) involves a network of hospitals and healthcare facilities supported by teams of nurses, specialists, general practitioners, and pharmacists. Off-label drugs are used to manage symptoms that do not respond to standard therapies, as permitted by law when no alternatives are available and under medical supervision. The National Health Service reimburses these drugs, but their use requires authorization based on proven safety and efficacy, potentially limiting patient access. Identifying essential drugs for symptom management is crucial to ensure a good quality of life.

What was done?

The AUSL of Reggio Emilia – IRCCS developed the “Local formulary of Palliative Care in Adult Patients” to support pharmacological management in PC. This formulary outlines key symptoms and provides evidence-based pharmacological options derived from scientific literature and clinical guidelines.

How was it done?

A multidisciplinary team of pharmacists, palliative care specialists, and nurses developed the formulary, defining essential treatments for palliative care across various local care settings. First published in 2019 and updated in 2022, the formulary specifies for each drug the indication, dosage, main side effects, and route of administration. Besides, it clarifies whether the use is in-label or off-label, based on the latest studies, accredited guidelines, and Italian legislation on off-label drug use. Off-label treatments are included to address multiple clinical needs when no approved therapeutic options exist, reducing empirical prescribing practices.

What has been achieved?

The formulary covers 16 symptoms, 99 drugs, and 30 active ingredients, ensuring continuity of care across the PC network. It allows PC specialists to prescribe listed medications, facilitating patient access to necessary therapies. This evidence-based system supports off-label use when approved options are unavailable, ensuring both patient safety and legal protection for healthcare providers. The tool is accessible to healthcare professionals through an electronic prescribing and administration system and in the company’s intranet section, promoting information sharing and continuity of care in hospital, community and home settings.

What next?

Clinical pharmacists play a critical role in ensuring appropriate prescribing and the proper implementation of the electronic system. Future steps include updating the formulary and expanding pharmacist training in palliative care

INCLUSION OF A CLINICAL PHARMACIST PHYSICALLY PRESENT AT THE EMERGENCY DEPARTMENT OF AN UNIVERSITY TERTIARY HOSPITAL

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European Statement

Clinical Pharmacy Services

Author(s)

JR ROMA, A RIZO, N POLA, B LOPEZ, A GARCIA, E BRAGULAT, M SANCHEZ, D SOY

Why was it done?

Several studies had been published claiming that the figure of a clinical pharmacist could improve the quality and safety of the medicines prescribed in the ED. However, little information has been published regarding its clinical impact when the pharmacist is physically present at the ED, which could enhance communication with clinicians and ED staff.

What was done?

A clinical pharmacist was included into the multidisciplinary team of the Emergency Department (ED).

How was it done?

The pharmacist performs their duties on-site from 8:00 a.m. to 11:00 a.m., Monday through Friday, joining the medical team located in the short stay unit (SSU) of the ED. The project was focused on validating and reconciling the medications of SSU patients who require short-term treatment, observation or reassessment of their initial ED treatment prior to discharge. Additional activities include logistical tasks, risk management and medication-related safety issues, with the identification of medication errors (MEs) during the pharmaceutical review. These errors are defined as any medication-related error, regardless of whether or not the patient experiences adverse effects.

What has been achieved?

During the first six months (December 2023–May 2024), 1904 clinical histories (patients) were reviewed (Mean day: 16 patients). MEs were found in 14.8% of the patients (282 patients), with a total of 338 MEs. Of these, 30.5% were reconciliation errors, 28.1% were overdosing errors, 15.1% were therapeutic duplicities and 8.9% were underdosing errors. Other identified MEs included: incorrect posology (3.8%), analytical value adjustments errors (3.0%), drug interactions (2.4%), incorrect duration (2.4%), adverse effects (2.1%), wrong administration route (1.8%), incorrect presentation (1.0%) and allergies (0.9%). The most common pharmacological class involved was antimicrobials (40.6%), followed by anticoagulants (13.2%), immunosuppressants (9.3%), and antihypertensives (7.8%).

What next?

Considering the overall satisfaction regarding the ED pharmacist figure in this setting, its work day in ED has been extended from 8:00 a.m. to 4:00 p.m. More research is needed in order to clarify if the role of the ED pharmacist working on-site at the ED can improve healthcare outcomes.

ENHANCING PROFESSIONALISM IN CLINICAL PHARMACIST SERVICE THROUGH DIGITAL COMMUNICATION

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European Statement

Clinical Pharmacy Services

Author(s)

Mia Pavelics Rehn
Trine Rune Høgh Andersen

Why was it done?

Clinical Pharmacists (CPs) in the Region Zealand Hospital Pharmacy (30 CPs) are scattered over great geographical distances on multiple hospital wards. When working with Clinical Pharmacist Services (CPS), usually just one CP is present per ward. All 30 CPs have different knowledge, seniority and specialization. To enhance the professionalism of the individual pharmacist on duty, digital communication such as chat functions are implemented for quick and easy intra-pharmacist consults.

What was done?

The ward physicians and nurses experience the combined specialty knowledge of 30 CPs from each CP when engaging CPS. This is highly relevant to maintain the position of having CPS through the hospital pharmacy instead of employing one individual CP directly on the ward, which has become more common over recent years.

How was it done?

To illuminate how the CPs from the hospital pharmacy share knowledge by using each other in their clinical operation, data was collected during three weeks of daily work. The CPs at 10 department wards registered each time they consulted a CP colleague. Furthermore, they recorded what type of communication they used (Microsoft Teams®, telephone or face-to-face) and what the inquiry was about. Written communication in Teams chat was saved for qualitative analysis.

What has been achieved?

The collected data illustrate the utilization of collective knowledge. In the three weeks 34 consults were made using primarily Microsoft teams. In 9 cases the contact was face-to-face and in 6 cases by phone. Most common was pharmacological discussion about specific cases during medication reviews (23), followed by questions about technical issues in the electronic patient record (11), general professional discussions (7) and consults about medication shortages and alternatives (8).

What next?

This initiative illustrates how using easy and available digital communication such as Teams chat functions across geographical distances will increase professionalism and harness the collective knowledge of many CPs working in collaboration for the benefit of improved CPS.

IMPLEMENTATION OF A SERUM MONITORING PROTOCOL FOR INFLIXIMAB IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE

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European Statement

Clinical Pharmacy Services

Author(s)

Mafalda Cavalheiro 1
Maria José Rei 1
Ana Rita Silva 1
Patrícia Batalha Silva 1
Carolina Marques 1
Miriam Capoulas 1
1- Pharmacy Department, Hospital da Luz Lisboa, Portugal

Why was it done?

Low serum Infliximab are associated with lost of response and development of immunogenicity. Moreover, therapeutic levels without the control of the inflammatory activity may inform about the necessity of changing the therapeutic class. While monitoring serum levels in the absence of response is already well established, the proactive monitoring of serum levels at defined timings during the induction and maintenance phases of therapy is beginning to be recommended by several leading organizations.

What was done?

Establishment of a protocol for proactive serum monitoring of Infliximab in inflammatory bowel disease, to guide the interpretation of serum levels, optimize dosage and therapeutic response.

How was it done?

Implementation took place in several stages. 1) Theoretical and practical training culminating in the discussion and drafting of a technical guideline including a monitoring protocol with the Gastroenterology team. 2) Organization of the sample collection and analysis circuit. The analytical technique is a rapid test that allows the detection of infliximab levels and anti-infliximab antibodies. 3) Finally, dosage optimization (maintenance of the reference dosage or intensification – shortening the administration interval or increasing the dose) is carried out with the support of population pharmacokinetic models using the DoseMeRx software, interpreted in the context of the overall response assessment in conjunction with the clinical team. The main limitation identified had to do with awareness of the medical team to rational dosage adjustments based on the population model.

What has been achieved?

15 patients were included with a median age of 33 years; 11 of these were diagnosed with Ulcerative Colitis and 4 with Crohn’s Disease. A total of 24 tests were carried out (21 with a proactive strategy and three with a reactive strategy). Of the doses taken at week 6, 60% were below the reference range considered. The dosage regimen was intensified in 64% of the recommendations. Of the patients analyzed, 76% maintained their response, although the duration of treatment was less than a year in most cases.

What next?

The strategy of proactive monitoring and dose intensification may have contributed to achieving and maintaining the response to treatment with Infliximab, but the small number of patients and the duration of the analysis call for further analysis.

PHARMACEUTICAL CARE AND CHARACTERIZATION OF PATIENTS WAITLISTED FOR KIDNEY TRANSPLANTATION IN A THIRD LEVEL HOSPITAL

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European Statement

Clinical Pharmacy Services

Author(s)

M. López López-Cepero, H. Padilla Castaño, G. Arrufat Goterris, P. Clares Rubio, T. Bonnin Garau, A. Tugores Vázquez, C. Martorell Puigserver.

Why was it done?

A pharmaceutical care consultation (PCC) was implemented for patients waitlisted for kidney transplantation (PWKT). The PCC focuses on transplant medication education, accurate medication history, allergy review, adherence assessment and self-perception of therapeutic complexity.

What was done?

Medication non-adherence is the major issue in transplantation, and it is associated with increased risk rejection, allograft loss and patients’ death.
Medication education after the transplant was not enough. Intervening before the transplant enabled pharmacists to know the patients and develop an individualized therapeutic plan, so the patients arrive as prepared as possible on the day of the transplant.

How was it done?

PWKT were scheduled in PCC and the pharmacist review their medical history and prescriptions. Patients were contacted by telephone for an interview. A face-to-face consultation was also possible.
PCC evaluate:
1) Clinical variables: etiology of renal pathology, comorbidities, previous transplantation, current renal replacement therapy (TRR), CYP3A5 genotype.
2) Medication: allergies, current medication plan, adherence (Morisky-Green test and electronic prescription record), organization and self-perception complexity.
3) Pharmaceutical interventions (PI): deprescribe or update current treatment, reinforce adherence, propose Monitored Dosage System (MDS) or pillbox, immunosuppressants education, arrange for a second PCC, contact with their community pharmacy, send to Pharmacogenetics Committee.

What has been achieved?

The PCC was implemented in June 2024. Among the first 4 months, 28 of the 58 PWKT have been evaluated.
Analyzing the clinical variables has allowed us to describe PWKT profile. Knowing how patients manage medication, as well as the perception they have about the importance of their treatment, helps to create an action plan and better prepare the patient for the transplant.
Given that one third of the patients were non-adherent, most of the PI focused on adherence reinforce, including additional monitoring, propose MDS or pillbox pillbox and resolve medication doubts.

What next?

The next step is to include a PCC in our clinical practice and get to visit all PWKT before the transplant.
It is needed to evaluate the impacts of PCC and PI as regards clinical outcomes. Detecting improvement actions will be enriching for patients care.
The PCC can be extended to other types of solid organ transplants.

PHARMACY TECHNICIANS’ DELEGATED ROLE IN MEDICATION ADJUSTMENT FOR HOSPITALIZED PATIENTS: IMPLEMENTATION OF THERAPEUTIC SUBSTITUTIONS AND DISCONTINUATIONS IN THE ELECTRONIC MEDICATION MODULE

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European Statement

Clinical Pharmacy Services

Author(s)

Maibritt Skov Olsen, Bernd Utech

Why was it done?

Pharmacy technicians at the Medical Ward of Bornholm Hospital adjusted medication orders to align with the hospital’s medication assortment. Operating under delegated prescribing authority; they prescribed, paused, and discontinued specific medications within a framework agreement and documented changes in the Electronic Medication Module “Sundhedsplatform” system.

What was done?

Patients often bring medications outside of the hospital’s assortment. Adjustment of these medications is time-consuming and can lead to documentation challenges. Delegating this responsibility to pharmacy technicians aimed to enhance patient safety by ensuring scan-ready medications and freeing up physicians’ time for other tasks.

How was it done?

A medication adjustment list was created by the pharmacy and department physician, outlining which drugs the technicians could adjust or discontinue. Pharmacy technicians were trained, and annual audits were conducted by the department physician. In a period of 13 days, a time study was made to track interventions; consultations with physicians, and time spent adjusting medications in the Sundhedsplatform.Nurses and physicians were asked about their experience of the pharmacy technician’s work.

What has been achieved?

During the test period, 97 patients were dispensed medication, and interventions was made for 39 (40%) of those patients. Technicians performed 60 interventions, of which 11 were physician-consulted. They spent 220 minutes on adjustments and notes, saving physicians 160 minutes. Feedback from nurses and physicians was positive, with improvements in medication scanning and reduced interruptions for physicians.

What next?

The task will be expanded to include all patients in the medical and surgical wards. An extension of the pharmacy technicians’ prescribing authority is also planned.

THE OCCURRENCE OF SHORTAGES AMONG COMMONLY USED MEDICATIONS AT COPENHAGEN UNIVERSITY HOSPITAL, AMAGER AND HVIDOVRE (AHH)

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European Statement

Clinical Pharmacy Services

Author(s)

Ina Vierø Rinder, IVR

Why was it done?

Handling medication shortages in the hospital pharmacy are time-consuming, and a lot of resources are used to find alternatives. Though shortages are a national focus in Denmark, shortages are not a priority focus in the local hospital pharmacy. Shortages are often handled “on-the-go” locally and therefore not prioritized. The hospital pharmacy uses “Medication News”, posted on internal website, to broadcast information about long-term shortages to the hospitals. The aim was to determine the occurrence of shortages among commonly used medications at Copenhagen University Hospital, Amager and Hvidovre (AHH).

What was done?

A top 100-list of most bought packages of individual chemical substances (ATC5-level) was generated. The purchase data were obtained from the hospital pharmacy at AHH for the period from October 2023 to September 2024.

How was it done?

The list was analyzed to determine how many medications had experienced shortage during the specified period. The analysis was conducted by reviewing past “Medication News”, historical e-mails regarding shortages, and the hospital pharmacy’s own record of shortages.

What has been achieved?

The top 100-list of most bought packages of individual chemical substances (ATC5-level) revealed a total of 1149 item numbers. The 500 item numbers in ATC-level V07AZ** (Chemicals and reagents for analysis) were excluded due to their use. Of the remaining 649 item numbers, 43 item numbers had experienced shortage during the specified period. Of the 43 item number shortages, 22 (51 %) had resulted in a “Medication News” on the internal website. The shortages were distributed in the ATC-levels A (16 %), B (9 %), C (5 %), D (2 %), H (9 %), J (12 %), L (5 %), M (7 %), N (30 %), R (2 %) and S (2 %).

What next?

The generated data of the top 100-list of used chemical substances has given rise to more attention on shortages in the hospital pharmacy. In the future it is assumed that the number of shortages will rise, and it should be possible to increase the attention of short-term shortages by using the obtained data e.g., integrate the data in a daily status meeting. Thereby the shortages can be handled as a priority and not “on-the-go”.

A COLLABORATIVE APPROACH TO IMPLEMENT SHARED CARE AGREEMENTS FOR AMIODARONE THERAPY

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European Statement

Patient Safety and Quality Assurance

Author(s)

K. Joyce, D. Jukes, F. Stewart

Why was it done?

In 2023, the drug formularies across Northeast and North Cumbria integrated care system were merged, with amiodarone allocated an ‘amber’ shared care status.

NHS England guidance recommends that existing patients taking amiodarone in primary care should be reviewed to ensure prescribing remains safe and appropriate and that a shared care agreement is introduced.

The pharmacy team aimed to implement this guidance, with minimum impact on clinician workload. The approach was steered by NHS England’s comments, in June 2024, regarding the importance of teams working together to meet the pressures and demands of primary and secondary care under the direction of the integrated care board (ICB).

What was done?

County Durham and Darlington Foundation Trust (CDDFT) pharmacy team worked collaboratively across the primary-secondary care interface to implement shared care agreements.

How was it done?

The ICB medicines optimisation team worked with the CDDFT pharmacists to engage GPs and cardiologists across the interface, creating a work-plan to share resources.

An audit tool was designed to capture patients prescribed amiodarone in the 61 GP practices across County Durham, which was completed by pharmacy staff within primary care networks.

Cardiology pharmacists in secondary care reviewed the data, triaging patients according to: indication, monitoring requirements, those requiring consultant review and those who could potentially stop treatment.

What has been achieved?

The audit, returning data for 129 patients, identified 93 patients without shared care. For half of these, discontinuation was considered as the National Institute for Health and Care Excellence explicitly recommends against use in atrial fibrillation. For the remaining, shared care agreements have been implemented with minimal impact on clinician time, primary care capacity and secondary care referrals.

The audit found 21% of patients without a shared care agreement were not receiving the recommended monitoring, compared to 100% receiving correct monitoring when one was in place. It may be anticipated that implementation will improve patient safety and experience through detection and avoidance of adverse events.

What next?

This initiative demonstrates the ICB and pharmacy successfully bridging care settings to improve patient care and experience and overcome challenges.

Building on these established relationships across the interface this work provides a model for sustainable collaboration on future shared care work.

72-HOUR TREATMENT RESPONSIBILITY AFTER DISCHARGE: CHARACTERIZATION OF MEDICATION-RELATED CALLS

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European Statement

Clinical Pharmacy Services

Author(s)

Daniel Rasmussen* and Morten Baltzer Houlind

Why was it done?

72-hour treatment responsibility (72H-TR) after hospital care is established to create a safe transition for the patient between hospital treatment and their home. After the implementation of 72H-TR, Copenhagen University Hospital, Amager and Hvidovre (AHH), experiences many calls from the municipalities related to patients’ medications. The purpose of this was to characterize calls related to medication in relation to 72H-TR.

What was done?

We reviewed logs from incoming calls made by Copenhagen and Høje-Taastrup municipalities regarding 72H-TR.

How was it done?

Calls related to patients discharged from the orthopedic or pulmonary medicine departments from AHH during the period from September to November 2023 were included. Further, two senior clinical pharmacists assessed whether calls related to medication was potentially preventable. In case of disagreement, consensus was reached between the reviews.

What has been achieved?

The results showed that 27 out of 50 (54%) calls were medication-related, and 22 out of 27 (82%) were potentially preventable. Of the medication-related calls that were potentially preventable, suboptimal communication was responsible for 11 out of 22 cases (50%), lack of a prescription accounted for 8 out of 22 cases (36%), and incomplete medication reconciliation accounted for 3 out of 22 cases (14%).

What next?

The next step will involve cross-sectoral and interdisciplinary workshops to identify barriers and facilitators and optimize the discharge process. We will also continue improving the online medication discharge reports available to municipalities to eliminate any ambiguities.

SYSTEMATIC PHARMACEUTICAL REVIEWS IN THE DISPENSING OF RESERVE ANTIMICROBIAL DRUGS

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European Statement

Clinical Pharmacy Services

Author(s)

Tea Stiplošek, Alenka Kovačič

Why was it done?

The growing misuse of antimicrobials, resulting in resistant microorganisms and more adverse reactions, has been identified as a significant concern. To tackle this issue, a system was put in place to systematically monitor the hospital’s dispensing and use of reserve antimicrobials.

What was done?

We established a system where each reserve antimicrobial prescription in the hospital is reviewed by a pharmacist, who decides whether to dispense the drug or suggest therapy adjustments. The dispensation of antimicrobial drug to the patient is then recorded in the patient’s medical documentation.

How was it done?

A special prescription form has been prepared, used exclusively for ordering reserve antimicrobials from the pharmacy in our hospital, separate from other medications. The form is reviewed by a pharmacist, who calculates the patient’s creatinine clearance, examines inflammatory markers, checks the alignment of treatment with the antibiogram, and reviews potential interactions with other therapies before deciding whether to dispense the drug. If necessary, the pharmacist suggests modifications to the antimicrobial treatment. Each time the antimicrobial is dispensed, it is recorded in the patient’s medical documentation for easier treatment tracking.

What has been achieved?

This approach has established systematic control over the prescription of reserve antimicrobial drugs, with a clinical pharmacist introducing an additional prescription checkpoint. Analysis of data from our work between 2020 and 2023 shows that during this period, we dispensed 16,464 courses of reserve antimicrobials, with pharmacists recommending therapy adjustments in 2,211 cases (13.6%). On average, we recommended dose reductions in 43.5% of cases due to impaired kidney function and dose increases in 23.5% due to improved kidney function or the need for appropriate dosing for specific indications. Pharmacokinetic monitoring (TDM) interventions, including those for vancomycin, amikacin, and gentamicin, accounted for 29.75% of the interventions, while 3.35% of our recommendations involved therapy changes due to inappropriate treatment based on antibiograms or the patient’s impaired kidney function.

What next?

We are digitizing the ordering system, allowing departments to request antimicrobial drugs directly through the hospital information system. We are also developing an application to calculate kidney function and verify the correct antibiotic dosage for each patient, all in one place.