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Author(s)

Sinem Şeker Şimşek

Why was it done?

In terms of medication and patient safety, to establish a safe non-cytotoxic medication preparation process, to ensure continuity of well-educated and motivated pharmacy staff are the key elements of pharmacy-based medication preparation units. This work aimed to share our experiences about how to be challenged with the risk in the drug preparation process during the pandemic as a university hospital pharmacy centered non-cytotoxic medication preparation unit.

What was done?

We have taken general precautions recommend by the World Health Organization. However, the protocol we have used to prepare Lopinavir/Ritonavir, Preparation of Hydroxychloroquine sulfate, Favipiravir and Hydroxychloroquine sulfate with Simple Syrup, Preparation of intravenous drugs (Tocilizumab)

How was it done?

The preparation of solid oral dosages, which should be administered to intubated Covid-19 patients through a nasogastric tube, was prepared by the ready to administration team of our pharmacy.
There is no evidence-based data on the bioavailability of these enteric-coated tablets after being crushed and administered to these vulnerable patients. The biggest challenge was lack of the reliable medication information sources. Before starting the Covid-19 medications preparation process, possible risks that could arise if crushed administration of these drugs were evaluated with a multidisciplinary team.

What has been achieved?

We suspended the Lopinavir/Ritonavir with dextrose during the preparation phase. We preferred the lavage syringe for intravenous administration risk elimination through ensuring patient and drug safety by preventing the risk of intravenous administration of the diluted suspended drug we have prepared. However, when we used a 3-way infusion manifold the strain during pushing and easy disconnection of the joints thus the risk of dose loss were the disadvantages.

What next?

The two pillars of dealing with the COVID-19 epidemic, which has affected the whole globally, are the proper preparation of the necessary medicines for treatment and the treatment itself. Drugs were prepared in line with the search for “a practical solution immediately” and the directives of the Ministry of Health and successfully administered to the patients. Our study is noteworthy as it shows that drugs can be prepared not only by the default ways but also by the different methods

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Author(s)

Xando Díaz-Villamarín, Ana Pozo-Agundo, Paloma García-Navas, Celia Castaño-Amores, Alba Antunez-Rodriguez, Cristina Lucía Dávila-Fajardo

Why was it done?

Pharmacogenetics (PGx) has the potential to predict patient´s drug response. Many genetic polymorphisms have been associated with variable drug response. This has been demonstrated with the highest level of evidence in fact many of them have been included in clinical dosing guidelines such as those from the Dutch Pharmacogenomics Working Group (DPWG) and Clinical Pharmacogenetics Implementation Consortium (CPIC). Actually, many drug labels include the recommendation about genotyping specific single nucleotide polymorphisms (SNP) prior to drug prescription.

What was done?

We have implemented pharmacogenetic tests in our hospital for a total of nine drugs.

How was it done?

Our hospital provides a PGx test service according to the following workflow. Physicians order the PGx test to the Pharmacy Unit, we take a saliva sample with sterile-cotton tipped swabs and send them to the Genomic Unit at Genyo. There, we extract the DNA and genotype the variants of interest. Genetic results are reported back to the Pharmacy Unit within 48-72 hours. After genotype-phenotype-recommendation translation according to the CPIC and DPWG dosing guidelines, we upload the dosing recommendation as a PGx report to the electronic patient´s medical history.

What has been achieved?

Since 2012, 2414 patients have benefited from our PGx test service for at least one drug-gene interaction. These tests have been requested by seven hospital departments with regard to a total of nine different drugs. We have reported 932 PGx dosing recommendations: Clopidogrel with 2013 genotyped patients and 845 dosing recommendations; Azathioprine with 208 and 21; Capecitabine: 48 and 1; 5-FU: 5 patients without recommendations; Tamoxifen: 117 and 48; Trastuzumab: 34 and 15; Irinotecan: 4 and 2; Simvastatin/Atorvastatin: 2 genotyped patients and no recommendations.

What next?

Since the first PGx test in 2012, we have been able to implement PGx tests in daily clinical routine in our hospital affecting 9 drugs. 2414 patients have benefited from this service and we are working on the implementation of new polymorphisms affecting drug response to expand our services.

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Author(s)

Lotte Deschepper, Kenny Noerens, Nilgün Kizilmese

Why was it done?

The COVID-19 pandemic caused limited availability of critical drugs and rapidly evolving treatment guidelines. Patient safety must be guaranteed at all times. However, the pandemic took the follow-up of drug shortages to an unprecedented level, increasing the risk of errors. Fulfilling this task was therefore difficult and new strategies needed to be implemented.

What was done?

In our hospital one pharmacist was dedicated fulltime to the COVID-19 drug management. Another pharmacist was committed to ensure the safe and efficacious use of drugs by conducting medication reviews and giving relevant drug and laboratory recommendations.

How was it done?

Microsoft Power BI ©, a tool to analyze data, was used to monitor the specific drug needs on the COVID-wards. Higher drug consumption was more rapidly detected and more specific actions could be executed. The available stocks in the hospital were also registered in a database and this information was updated and reported daily to the medical staff. In this way treatment guidelines could be proactively adjusted if necessary. Medication alerts were sent regularly by mail to ensure that all health care providers were informed about (temporary) changes in order to reduce the risk of medication errors.
Additionally, pharmacists collected evidence‐based drug information concerning indications, dosing, possible side effects, drug‐drug interactions and other precautions based on (inter)national guidelines. This information was used to develop a back-office validation tool that supported pharmacists to conduct medication reviews in a uniform manner. Daily updated reports from Microsoft Power BI © were used to analyze relevant interactions and contra-indications. Pharmaceutical recommendations were promptly documented and reported in the medical record of the patient and the physician was contacted immediately if urgent.

What has been achieved?

Due to the multi-disciplinary approach and guided medication use, therapy continuation could be guaranteed for all patients. Our validation tool resulted in the early detection and interception of medication errors ensuring patient safety.

What next?

A retrospective risk assessment will be done to evaluate our approach and a disaster plan concerning medication will be established based on our experience. The development of a computer-based analytical tool will be encouraged to maximize patient safety while minimizing risk of medication errors.

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Author(s)

SOFIA KONSTANTINIDOU, VANGELIS KARALIS

Why was it done?

Tyrosine kinase inhibitors (TKIs), like erlotinib and gefitinib, are widely used in anticancer therapy. However, after long term administration of TKIs, resistance is observed in the majority of patients. Thus, it is necessary to be able to define individualised dosage regimens for TKIs in cancer patients. Nowadays, modelling and simulation approaches represent the most powerful tool in the hands of clinical pharmacists towards precision medicine.

What was done?

Population pharmacokinetic (PK) – pharmacodynamic (PD) modelling was utilised to simulate erlotinib and gefitinib dosage regimens for non-small cell lung cancer. In silico clinical trials with virtual patients, of several resistance levels, were simulated in order to optimise pharmacotherapy and get better therapeutic outcomes.

How was it done?

The utilised PK/PD model and average parameter values were obtained from the study of Eigenmann and colleagues. This model was fully validated using statistical criteria and goodness of fit plots. In order to simulate many possible conditions that may occur in clinical practice, several different values of erlotinib and gefitinib clearance, absorption rate, pharmacodynamic characteristics (like tumor volume), and resistance were assessed. In addition, several dosage schemes were simulated. The entire modelling work was performed in Monolix® 2019R1.

What has been achieved?

Concentration vs. time and effect vs. time plots for the virtual patients were simulated for a variety of conditions and tumour resistance levels. For both TKIs, decrease of body clearance led to higher plasma concentrations, as well as more intense and longer duration of the effect (i.e. tumour volume shrinkage). Enhanced drug effect on resistant cells resulted in a decrease in tumour volume. In addition, a variety of concentration-time profiles were simulated, making it possible to choose the best regimen for each patient.

What next?

In this study, the use of modelling techniques led to the simulation of many conditions of patients and adjustment of dosage regimens according to their needs. Wider application of in silico methods using virtual patients will allow the design of the most appropriate individualised dosage schemes tailored to the patients’ requirements.

Author(s)

Paul Firman, Karen Whitfield, Therese Hayes

Why was it done?

The provision of outpatient oncology services by pharmacists is still limited, but this role is an emerging one. There is limited literature to date that suggests that pharmacists can add value while satisfying the needs of patients with cancer, addressing medication use and symptoms, and potentially generating revenue for the practice. The value that clinical pharmacists can bring to outpatient clinics other than oncology clinics has been highlighted extensively, providing added weight to the argument for incorporating these professionals into the cancer care model.

What was done?

The oncology pharmacy team in a tertiary referral hospital with the assistance of activity-based funding commenced an outpatient clinic allowing patients an opportunity for medication reviews, appropriate counselling of oral chemotherapy and discussion of medication side effects which was a gap within the current service.

How was it done?

In consultation with pharmacy, medical, nursing and administrative staff a working party was formed to establish the outpatient pharmacy clinic. Factors including patient cohort, appointment scheduling, clinic room availability, referral methods, and key performance indicators were discussed. The group met monthly to discuss the progression of the clinic and any barriers.

What has been achieved?

Over the first 3 months (January – March 2019) 215 patients on an average of 7.5 medications were reviewed. Within the cohort 57% of the patients were taking high risk medications (known as PINCHA medications) and 37% received counselling on new medications. There were 37 medication interventions mostly involving drug−drug interactions and medication optimisation. For succession planning, pharmacist training has also occurred.

What next?

Outpatient oncology practice is a growing area of opportunity for pharmacists to provide clinical services as part of a multidisciplinary team. This is of benefit both to the multidisciplinary team and the patient, ensuring the best possible outcomes. With the growing complexity of oncology treatments, the pharmacist’s role is vital to ensure quality use of medicines, safety and patient centred care. Training is currently being undertaken to expand the role and to ensure continuity of the service.

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Author(s)

Karina Doherty

Why was it done?

VTE is a collective term for blood clots usually in the legs or lungs. In Europe, there are 544,000 VTE-related deaths every year. VTE is responsible for more deaths than AIDS, breast cancer, prostate cancer and motor vehicle accidents combined. SVPH Pharmacy Department has been conducting annual Clinical Audits on VTE prophylaxis using a paper based system. However, the process was time consuming and limited the frequency of audit and the opportunities for identifying opportunities for improvement in compliance. SVPH has a high number of patients with high risk of VTE including Medical Oncology patients and Surgical patients. Compliance rates over preceding years were running at 75%; however, it is hoped to achieve a target of 90% compliance by 2020.

What was done?

An App was developed to collect data on venous thromboembolism (VTE) prophylaxis compliance across St Vincent’s Private Hospital (SVPH)

How was it done?

Different technologies were explored and an App developer was selected. Funding was sourced. Stakeholders were invited to get involved in the development team; this part was challenging and a lot of negotiations were had as to how the format of the App would be developed and carried forward. The next step when all the details had been finalised was launching the App.

What has been achieved?

Every month seven patients are randomly selected for audit and an auditor (in SVPH a pharmacist) inputs the data on the App which the lead auditor analysis. At SVPH compliance has increased from 75% prior to the app, to post implementation of the App where monthly VTE audits were conducted on all inpatient wards. The results are 92% compliance with VTE prophylaxis for 2018, and for 2019 up to Sept 2019 96% compliance.

What next?

It is hoped that this App will be a useful tool that will help SVPH and other hospitals to achieve a higher compliance with VTE prophylaxis guidelines and help prevent clots in patients. This App can be customised to individual hospital requirements. Technology has been shown to assist with clinical audit and will be used in various projects to make auditing easier and faster and therefore help healthcare workers to provide a better service to patients.

Author(s)

Chiara Inserra, Antonio Solinas, Chiara Panciroli, Branden Nemecek, David Zimmerman, J.Douglas Bricker, Piera Polidori

Why was it done?

Successful implementation of clinical pharmacy services are associated with improved prescribing practices. SIFO includes clinical pharmacy in their mission to line up with Section 4 of the European Statement on Hospital Pharmacy and is striving for implementation through advanced trainings for IHPs. The aim of this EP was to provide real world clinical pharmacy training to IHPs.

What was done?

Through international collaboration between Duquesne University School of Pharmacy in Pittsburgh (PA-USA) and the Italian Society of Hospital Pharmacy (SIFO) a clinical pharmacy exchange programme (EP) was established to provide clinical education to Italian pharmacists interested in advancing the profession. From 2010 to 2018, SIFO provided several grants to allow Italian hospital pharmacists (IHPs) to participate. In 2018, three IHPs from across Italy were selected for a 1 month experience to gain experience and insight into practices that they may use in their facilities.

How was it done?

The clinical training was created by Duquesne University to provide IHPs educational and first-hand clinical skills based on American clinical pharmacy practice and education. The training was individualised for IHPs’ interests including didactics and practical training. Sessions to discuss IHPs’ progress were conducted with the Dean and faculty of the programme.

What has been achieved?

IHPs had the chance to observe American pharmacy education and compare it to the Italian one. American university training was practical, well-coordinated with clinical activities, and based on a trustful teacher-student relationship. During practical training IHPs shadowed American Clinical Pharmacists (ACP) specialized in different areas: Infectious Disease, Cardiology, Oncology, Emergency Medicine, Internal Medicine, Community Pharmacy, Ambulatory Care. They were able to observe how ACPs validate prescriptions and are actively engaged in direct patient care, participating in bedside multidisciplinary rounds and making recommendations on therapies (drug interactions, dose adjustments, antibiotic selection). IHPs saw how technology investments, prioritisation of care, and availability of skilled personnel underlie American hospital pharmacy practice.

What next?

IHPs gained baseline clinical pharmacy skills to enhance care at their facilities; however, the widespread implementation of clinical pharmacy in Italy requires education reform, enhanced resources and integration of pharmacists within a multidisciplinary team. Implementation of small projects through collaboration with universities should be considered in the Italian hospital setting.

Author(s)

Mia P von Hallas, Trine RH Andersen

Why was it done?

Physicians in acute wards have limited time to see all patients. Time for medication history, reconciliation and review is limited, due to great patient turnover. The physicians did not consider the pharmacist medication review alone as a contribution to the workflow or to relieve the high workload.

What was done?

Through user surveys among the physicians in the Acute Ward, pharmacist tasks were adjusted to benefit the physician’s high work flow. Before the survey, pharmacists performed medication reviews which were communicated to the physician. The adjusted pharmacist tasks on the ward includes medication history, reconciliation and transfer of the medication to the electronic medicine module (Epic), securing up-to-date medicine data during hospitalisation.

How was it done?

A questionnaire was developed regarding four areas (Pharmacist competencies, Pharmacist tasks, Pharmacist medication review, Multidisciplinary teamwork) and distributed among the physicians. Based on the anonymous responses, the pharmacists adjusted their tasks to include medication history, medication reconciliation and transfer of medication to Epic, complying with the suggestions in the questionnaire survey. Obstacles were low percentage of respondents (15/33 (45%) prior to the initiative and 12/39 (31 %) after), and the large replacement of junior physicians in the period between surveys.

What has been achieved?

Pharmacists feel more part of the multidisciplinary team and attitudes towards the pharmacist service among physicians has changed. A new survey after implementation of the new workflow showed that 73% found medication reconciliation was a pharmacist task, compared to 29% before. After implementation, 90% of physicians believed that pharmacists could do medication review (67% before intervention). The acknowledgement that pharmacists were able to transfer medication to Epic was increased from 20% to 90%. The attitude has changed from considering pharmacists as medication advisers to considering pharmacists as part of the multidisciplinary team in the ward.

What next?

The questionnaire survey will be repeated annually to continually improve the workflow and contribution of clinical pharmacist services to the heathcare professional team in the acute ward.

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Author(s)

Sarah POGGIO, Anne-Sylvie DUMENIL, Sandrine ROY, Claire HENRY

Why was it done?

BPMH on admission has been performed in these departments since 2011. An analysis of the process and prescriber use of BPMH highlighted an underutilisation; average consultation rate was 29.8%. The main reasons were the online publishing interval of the BMPH and competition with the AC report which also displays medication. A previous study showed a 70% rate of patients with unintended differences between BMPH and the AC report.

What was done?

We redesigned the pharmaceutical care process for programmed patient circuits in orthopaedic and visceral surgery by providing the “best possible medication history” (BPMH) in the patient’s electronical medical record (EMR) before anaesthesia consultation (AC).

How was it done?

Due to a lack of coordination, we exchanged using surgery with anaesthesia schedules to select patients, thus improving prioritisation. We created support documents for students, describing how to conduct a phone interview in order to reassure unfamiliar patients, to gather useful data (GP, pharmacy, prescription) to produce a BPMH, to visit inpatients when admitted to confirm the BPMH’s accuracy and to assess patient satisfaction with the process. We trained 6 students and presented our work at an anaesthetist staff meeting.

What has been achieved?

Among 195 patients included from June to October 2019, 70.2% BPMH before admission were successfully published online (137/195), 67 went through the complete care path (from home to discharging), 12 never came for AC and/or surgery, 58 were published but waiting for patient’s admission and 58 failed. The reasons we failed to publish on time included inability to reach patients (31.6%), lack of sources (21.1%), time shortage before AC (17.6%), surgery cancellation (14.0%) and refusal (7.3%). 1.58 (±0.85) calls were needed to reach a patient, 13 BPMH required modification after admission (19%), and patient satisfaction on average was 5.11/6 when asked whether the call, the medication management during hospitalisation and the confirmation interview went well. Finally, the consultation rate of BMPH evolved from 29.8% in 2017 to 72% since we changed practices.

What next?

Implementing this new process in the care path streamlines information transfer between the different stakeholders (anaesthetists, surgeons, pharmacists) and provides a better integration of pharmaceutical care in surgery wards as an efficient support system for prescribers.

Author(s)

Ángel Guillermo Arévalo Bernabé, Pilar Lalueza Broto, Jordi Serracanta Doménech, Jacinto Caparrós Baena, José Manuel Collado Delfa, Jordi Aguilera Sáez, Romy Rossich Verdés, Pablo Sánchez Sancho, Juan Carlos Juárez Giménez, Maria Queralt Gorgas Torné

Why was it done?

The burns unit of a third-level hospital includes a patient’s great heterogeneity depending on his population group and his clinical condition (extension, degree and depth of his burns, etiological agent of the burns and associated comorbidities), which makes the managing of these patients complex and they need multidisciplinary solutions. In addition, extensive burns provoke physiopatological alterations that involve changes in the pharmacokinetical and the pharmacodynamical modelling of some drugs. The knowledge that the pharmacist has about the changes that take place in vascular dynamics, the clearance and the distribution volume of the drugs, and the degree of union from these to plasmatic proteins, makes his active participation in the care of the burns patient, and in the optimisation of his pharmacotherapeutic plan, very interesting.

What was done?

The integration of the pharmacist into a multidisciplinary group of assistance to the burns patient constituted as the Managing Committee of Cases and was integrated by plastic surgery, intensive medicine, intensive paediatric medicine, preventive medicine, infectious diseases, psychiatry, psychology, social work and infirmary, as well as pharmacy.

How was it done?

A protocol was devised that standardises and systematises the review of the pharmacotherapeutic plan of all patients in the burns unit, including burn critical and paediatric. Also, there is included a model of record and codificate of pharmaceutical interventions. The multidisciplinary group meets weekly and every patient is analysed from all clinical points of view, the pharmacist intervening in relation to the pharmacotherapeutic and nutritional plan.

What has been achieved?

The active integration of the pharmacist has been achieved in the clinical group of assistance to the burns patient. In addition, there has been created a collaborative attitude that has benefited joint projects of investigation. The degree of acceptance of the offers of modification that the pharmacist realises is 90%.

What next?

The following step must be, depending on the obtained results, to establish improvement assistance measures, including the accomplishment of protocols and the development of investigation projects that help to generate knowledge about the use of some drugs in burns patients, such as immunoglobulin or proteolitic enzymes for the extraction of bed sores.