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Author(s)

Dora Mueller, Maria-Theresia Pichler, Karin Kirchdorfer, Kora Koch

Why was it done?

Prior to the implementation, insufficient time resources did not allow for clinical pharmacy services (CPS) on all surgical wards. Existing cover was not efficient or effective as drug-charts were often not available or patients discharged before pharmacy suggestions were implemented. The integration of the CPS into the centralised admission process instead of the wards resolved these shortcomings and facilitated pharmacy input to all surgical patients using this admission process.

What was done?

A central surgical admissions process was launched at a 450-bed teaching-hospital in April 2018 in which patients are seen five days before surgery by an interdisciplinary team. A new clinical pharmacy service (CPS) was implemented on-site to review patients’ medical history comprising three consecutive steps:
1. Medicines reconciliation is completed based on existing patient-consultation records.
2. Recommendations for switching drugs to the hospital formulary on admission are noted on the drug chart.
3. Medication review is carried out to improve inpatient medication safety, and changes are communicated to medical staff via e-consult.

How was it done?

This proactive concept highlighting the advantages of interdisciplinary CPS and reflecting international evidence (e.g. patient safety, patient care, workload reduction for medical and nursing staff) convinced hospital management of its need. Resource implications included allocation of a pharmacy office on-site, development of a standard operation procedure and support for interdisciplinary teamwork on-site.

What has been achieved?

Between April and September 2018, records of all patients using the new process (n = 1527) were reviewed by a clinical pharmacist. At least one drug-related recommendation was made for 38.6% (n = 589) of all patients taking medication. This development enhances the clinical pharmacy workforce at our hospital and contributes to the quality of the admission process. Feedback from medical and nursing staff, hospital and quality management was positive throughout. We observed an improved level of awareness, higher numbers of requests for other CPS and a better understanding of the clinical pharmacists’ role within the healthcare team.

What next?

This initiative reflects how CPS can be expanded and optimised by seizing the opportunity and using existing resources. This model may be adapted for other hospital inpatient settings.

Author(s)

Gregorio Romero Candel, Maria Jesus Sanchez Cuenca , Nieves Cano Cuenca, Jose Marco del Rio , Julian Castillo Sanchez, Luna Carratala Herrera

Why was it done?

The healthcare provided in the SSC is not fully integrated into the structures of the National Health System. These patients present a higher risk of adverse events related to pharmacotherapy, due to patient factors, with the treatment, the health system and the institutionalisation. The integral approach of the pharmaceutical benefit was necessary for improving the efficiency, safety, health and economic results due to the process using drugs and other health products in the SSC.

What was done?

A pharmacotherapeutic benefit model has been started through the hospital pharmacy to the Socio-Sanitary Centres (SSC) of our health area. A pharmacotherapeutic management system based on the evaluation and selection of drugs and diet therapy items has been established.

How was it done?

An adherence protocol was made to the hospital pharmacy service, with the benefits that were to be provided to them. A guide was prepared with drugs and nutritional supplements that were available to them according to the Pharmacotherapeutic Guide of the Hospital Pharmacy Service, thus guaranteeing the most efficient products. A request model of both drugs and dietotherapics was developed for the SSC, assigning each centre one day per month to request the order and another day of dispensation. Finally, a calendar of distribution routes for each SSC was prepared.

What has been achieved?

For 12 months, eight SSC have been assigned to this programme, with 538 patients. Twelve shipments have been made to each centre, which have been provided with a total of 682,484 units of 223 active ingredients. The dispensation in diet therapy contained 28,045 units of 13 specialties. It has been possible to improve the pharmacotherapeutic coverage of these patients and reduce the expenditure on drugs in the area through centralised supply.

What next?

Development of follow-up programmes for patients with high health or economic impact drugs. Also, the adherence of new SSC, as well as increasing the dispensing portfolio, and achieving the integration of information systems, to have a total traceability from the patient to the different assistance levels.

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Author(s)

Nina Kærgaard Hansen

Why was it done?

The initiative was performed to investigate the accessibility and usability of the current intranet in order to improve intranet information and communication from the hospital pharmacy to the clinic.

What was done?

Workshops with usability tests were performed with four different professions who are expected to use the intranet information and communication from the hospital pharmacy.

How was it done?

Workshops for selected professionals including pharmacists, pharmaconomists and nurses were held. The workshops consisted of four parts:
1. Video capture and recording test: Participants were asked to find specific information on the intranet. Comments, clicks and movements of the mouse were recorded during the task.
2. Sorting and prioritization the pages: Participants were given screen shots of 57 pages from the intranet. The participants were asked to sort the pages in three categories: need to know, nice to know and insignificant.
3. Evaluation of selected texts: Participants were given 5 examples of texts from the intranet and asked to assess if the text was relevant and understandable.
4. Structured focus group interview: Using a structured interviewguide the use and challenges experienced by the participants were explored.

What has been achieved?

From the present initiative it was found that the structure of the intranet was not optimal and did not reflect the daily needs from the users. The results from the workshops provided a clear guideline on how to restructure the intranet. It is important to make short cuts and optimize search function.
In addition, the initiative revealed how to improve texts:
– Write shortly, concisely and action oriented: “Tell us what to do”.
– Write the most important first, then elaborate and insert links to learn more.
– Use subheadings for skimming the text.

What next?

A campaign is planned to advertise the new intranet structure. Number of users and subscribers on the intranet pages is followed to see if the activity increases. Editors have been educated to write texts that are short, concise and written in an action oriented language

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Author(s)

Janne Jensen, Solvej Wandy Pedersen, Susanne Nørregaard, Karin Herkell, Anne Thestrup Nielsen, Anita Gorm Pedersen

Why was it done?

A group of hospital pharmacists representing all hospital pharmacies in Denmark have in a previous study identified and slimmed a national portfolio of extemporaneous pharmaceutical preparations used by Danish hospitals from a total of 2,754 preparations down to approximately 750 preparations being considered of clinical importance. Without a common overview of the national portfolio there will be initiated production of duplicates and almost identical products resulting in a large and inconsistent portfolio.
The purpose of this GPI was to make the national portfolio of extemporaneous pharmaceutical preparations accessible to all hospital pharmacists in Denmark and to implement a common procedure to evaluate preparations before adding them to the national portfolio to avoid duplets and obsolete products.

What was done?

A common national procedure for adding new preparations to the national portfolio was developed and implemented to avoid duplets and to ensure a uniform quality and appropriate risk assessment of the preparations.

How was it done?

A national database was developed and tested. Each hospital pharmacy entered their own extemporaneous pharmaceutical preparations in the database. Also, the extemporaneous pharmaceutical preparations manufactured by community pharmacies and used in the hospitals were entered in the database.
One hospital pharmacist in each of the five regions in Denmark was appointed as gatekeeper for the national portfolio. A template for an application form for new preparations was developed. When a physician requests a new preparation the application form will be completed by the clinical pharmacist. It is forwarded to the gatekeeper who will evaluate the preparation before approving it as a candidate for the national portfolio.

What has been achieved?

430 extemporaneous pharmaceutical preparations from the hospital pharmacies are entered and quality approved in the database. 255 extemporaneous pharmaceutical preparations manufactured by community pharmacies were entered in the database.
A national group of five gatekeepers was formed, and the workflow for both the group and the individual gatekeeper was described and implemented at all Danish hospital pharmacies.

What next?

The GPI provides an easy-accessible overview of the national portfolio of extemporaneous pharmaceutical preparations, releasing production time and resources at the manufacturing pharmacies.

Author(s)

Roisin O’Hare, Andrew Dawson, Natasha Beattie, Eva McRory, Jayne Agnew, Sara Laird, Tracey Boyce, Victoria McConville

Why was it done?

In November 2016, regional funding was provided to all of the Trusts in order to improve medicines reconciliation rates within 24 hours of admission. The weekend clinical pharmacy service to the emergency department was established from 1st December 2016.
The aim of this project was to examine the impact of a clinical pharmacist led weekend service on to the Emergency Department in xxxxxxx.
Objectives
To determine the number of medication histories and medicines reconciliation completed within 24hrs of patient admission
To evaluate the type and signficance of pharmacy interventions identified
To record the number of medications prescribed by the pharmacist.

What was done?

A pharmacy service to optimise medicines use and pharmaceutical care for patients in the emergency department at the weekend was established.

How was it done?

We conducted a literature review on the existing clinical pharmacy services to ED. We used an Agile methodology. We established a core stakeholder group to develop a vision and a plan for the project. We used an Agile methodology with Plan Do Study Act (PDSA) with weekly ‘scrums’ and 6-8 weekly sprint meetings. We developed a data collection form to collate quantitative data; including the number of; patients reviewed by the pharmacy team, medication histories completed, medicines reconciliation completed within 24hrs of admission, pharmacist interventions, medications prescribed by the pharmacist.

What has been achieved?

We demonstrated an increase in the number of patients reviewed per day since December (average of 10) to June (average of 12). We increased the Medicines Reconciliation rate in the ED in xxxxxxx within 24hrs of admission from 0% in Nov 2016 to ~60% in Dec 2016 and ~80% in August 2017. The Pharmacy Team made on average 4.5 interventions (range 3-6) per patient reviewed (an average of 45 interventions per day). Prescribing by pharmacists demonstrated an increase in the number of medications prescribed per patient; December (0) and August (4).

What next?

The pharmacist interventions directly improved patient safety and care. Staff in the ED have anecdotally praised the service to the Pharmacy Team and have increasingly accessed the knowledge of the pharmacist at the weekend to address medication-related problems. We believe that we shaped an approach to clinical pharmacy practice in the ED which could be shared across the Trust and further across the country.
References:
1. Medicines Optimisation, the safe and effective use of medicines. Available from: http://www.nice.org.uk/guidance/ng5 Accessed on 13th October 2017.
2. Eadon H. Assessing the quality of ward pharmacists’ interventions. Int J Pharm Practice. 1992;1:145–7.
Acknowledgements:
We would like to acknowledge the work of the entire clinical pharmacy and clinical pharmacy technician staff at xxxxxxx who provide this service to the ED at the weekend and who tirelessly collected the data for this project.

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Author(s)

Gösta Lööf, Malin Kuno Edvardson, Jessica Loayza, Louise Furubom

Why was it done?

According to national guidelines, 60-70% of women >50 years with a fragility fracture should receive treatment to prevent further consequences of osteoporosis. In Sörmland, only about 16% of eligible patients received such treatment in 2015. To increase this number it was decided to start a coordinator-based FLS. CPs were chosen as coordinators since they were already integrated members of the health-care team at the clinic, conducing medication reviews, with the required competence to assess patients and suggest suitable medication therapy for osteoporosis.

What was done?

By initiative of the county task force for osteoporosis in the county of Sörmland, Sweden, a project with a fracture liaison service (FLS) with clinical pharmacists (CPs) as coordinators was developed in collaboration with the orthopedic clinic at one of the region´s hospital; Mälarsjukhuset.

How was it done?

The project was initiated in December 2015. The CPs were given permission to send electronic referrals to DXA to be performed and to the general practitioners (GPs) for further investigation and initiation of treatment for osteoporosis. The CPs identified eligible patients at the orthopedic ward and at the emergency department (ED). The CPs visited and interviewed patients treated at the ward while patients treated at the ED instead received a phone call or a letter, to get information regarding their risk factors. Thereafter the CPs decided how to proceed; referral to DXA, referral to a GP or no further investigation or actions. For patients treated at the ward, the CPs would discuss their findings with the orthopedist on duty.

What has been achieved?

For patients included from December 2017 to October 2016, the percentage of who received treatment has raised to at least 25%. For about 50% of the patients, a full year has not yet passed since the date of fracture so the result may still improve. According to two small surveys, the orthopedists and the GPs are very positive to the new service and want it to continue.

What next?

Because of the success, the service will be permanented and implemented thoroughout the county. Opportunities to further improve FLS have been identified continuously and changes made accordingly to reach the goal of 60-70% treated patients.

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Author(s)

Gregorio Romero Candel, Esther Domingo Chiva, Nuria Martinez Monteagudo, Jose Marco del Rio, Marca Diaz Rangel, Francisca Sanchez Rubio, Ismael Perez Alpuente, Eva Garcia Martinez, Ana Valladolid Wals

Why was it done?

The ED is an area where medication errors are common given it´s complexity, the large number of patients with different pathologies, having to make quick decisions with little clinical information and the coexistence of professionals with different training.
The use of intravenous (IV) and high risk drugs, as well as the mixture of two or more intravenous drugs in the same diluent are usual and can lead to medication errors.
We designed an educational program based on a session for nurses of the ED to standardize the use of the most commonly administered drugs and improve patient safety

What was done?

A training session for nursing staff on safe drug administration in the emergency department (ED) was performed

How was it done?

A training session was conducted by the fourth year resident during a two month rotation period in this area. The most common mistakes were presented to nurses based on national studies, as well as techniques for safe administration of drugs. Guides on parenteral administration of the hospital were reviewed with special emphasis on high risk drugs and how to manage them according to the Institute for Safe Medication Practices. We also developed a guide including the most frequent drug incompatibilities and direct intravenous administration of drugs for the ED.

What has been achieved?

The aim of the session was to train personnel at the ED in order to reduce medication errors and promote a safety culture. In turn, the development of guidelines to standardize clinical practice are useful, making information accessible and easy to use. Clinical sessions between departments allow the integration of the pharmacist in other areas.

What next?

We are still working with the ED to increase safety in drug therapy by developing new pharmacotherapeutic protocols (high risk medications protocols, perfusion protocols and new safety guidelines and training sessions). We are also working with more departments at our hospital with the experienced gained

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Author(s)

Janne Kutschera Sund, Martin Grotnes, Ingvild Klevan, Lene Lilleaas, Johan Fredrik Skomsvoll

Why was it done?

Lack of comprehensive strategies and funding has made it difficult to develop and implement extensive clinical pharmacy services in our hospital. It has been challenging to secure hospital involvement. A new financial model securing funding from the regional health authority made way for a new joint approach.

What was done?

A dialog based process involving hospital management, clinicians and the pharmacy led to a large increase in clinical pharmacy services in our university hospital.

How was it done?

A literature review was conducted. Based on this, a multidisciplinary project group decided that all clinics and wards were eligible for clinical pharmacy services and should receive extensive information on the topic. As there were limited resources allocated, all clinics were asked to apply for the service. The hospital management received applications three times the number of funded clinical pharmacists.
Prioritizing was based on the following criteria; use of the Integrated Medicines Management (IMM)-method, patient flow, evaluation and research, in- or out –patient clinics, continuation of established services, localization and time schedules on the wards.

What has been achieved?

The long term funding of clinical pharmacy in the health region enabled the hospital pharmacy to recruit and educate highly competent clinical pharmacists.
In less than a year, the number of clinical pharmacists has increased from three to twelve. The number of wards receiving clinical pharmacy services has also grown from three to twelve and there are still plans for further implementation.

The hospital and the ward managements are much more involved in evolving a common patient safety strategy with focus on medication. Specific quality indicators for each patient population and ward are being developed, and clinical pharmacists are now important members of multidisciplinary teams all over the hospital. Pharmacists are integrated in ongoing clinical research projects and publishing.

User surveys show that clinical pharmacy is assessed as a highly beneficial service by both nurses and physicians.

What next?

Develop the IMM-model to include the clinical pharmacists in standard patient care in every clinic and department. We plan to perform follow-up studies on the effects of clinical pharmacy services in different settings.

Author(s)

Tine Van Nieuwenhuyse, Sabrina De Winter, Isabel Spriet, Thomas De Rijdt

Why was it done?

During the last decade, healthcare shifted in many ways towards a more patient-focused rather than a disease-focused approach. Hospital pharmacy services experienced a similar development. Traditional drug-oriented services expanded towards patient-oriented services by imbedding computerized clinical decision support (CCDS) in the prescribing process and implementing bedside clinical pharmacy services, both leading to improved efficacy and safety of medication use. However, due to limited resources, clinical pharmacy services are not implemented on a hospital-wide basis in Belgian hospitals.
To guarantee patient safety throughout the hospital, emphasizing patients at risk, we started in March 2016 with the development and implementation of central check of medication appropriateness.

What was done?

Development and implementation of central check of medication appropriateness (COMA) in hospitalized patients in a 2000-bed academic hospital.

How was it done?

Based on a risk analysis, high risk prescriptions are checked by a hospital pharmacist for appropriateness. A daily check (0.5 FTE) of automatically generated queries is performed using standardized algorithms. The queries are a result of the screening of all new prescriptions in the electronic prescribing system of the last 24 hours. If an urgent intervention is necessary, in case of a serious adverse event, a phone call is carried out to the treating physician. In all other scenarios, interventions are performed via electronic warnings in the patient’s file.

What has been achieved?

– Development of 75 specific algorithms covering 5 pharmacotherapeutic areas of interest: drugs with restrictive indication, medication-related biochemical changes, evaluation of overruled interventions raised by CCDS, reimbursement of drugs, sequential therapy for bio-equivalent drugs.
– Education of 8 pharmacist involved in the COMA
– During a 6-month period, 19220 prescriptions were checked for which 8284 (43%) electronic warnings were sent and 224 (1%) phone calls were carried out. When analysed without automatic warnings for sequential therapy, 11751 prescriptions were checked for which 815 (7%) electronic warnings were sent and 224 (2%) phone calls were carried out.

What next?

For the future we obtain next goals:
• Evaluation of the current COMA, with emphasis on improving specificity
• Development of new algorithms , also expanding to other areas of interest
• Development of an easy access training tool for hospital pharmacist to perform COMA

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Author(s)

Caroline Hynes, Dolores Keating

Why was it done?

Psychiatric intensive care is for patients who are in an acutely disturbed phase of a serious mental disorder. Psychotropic medicines play a pivotal role in the treatment of these disorders which is why the pharmacist is a key part of the patient care team. The introduction of a designated pharmacist to address not only the clinical needs of the PICU team but also the medicines information needs of the patient was essential to optimise patient outcomes.

What was done?

A liaison pharmacist was assigned to the psychiatric intensive care unit (PICU) to provide both a clinical pharmacy service including regular medication chart review and development of patient-centred clinical guidelines, and to provide medicines information and support directly to patients.

How was it done?

The main obstacle to the introduction of this initiative was establishing a relationship with patients, as visible pharmacist interventions were new to patients on the PICU. In order to overcome this obstacle, the pharmacist was required to be present on the unit and regularly meet patients to enquire about their experience of taking medicine for their mental health and provide information as required.

What has been achieved?

• The pharmacist hosts a weekly medicines information group on the unit where; medicines are discussed openly, patients are provided with medicines information leaflets and medicines charts detailing all of their current medicines and what they are for, and those taking antipsychotics are systematically assessed for side-effects

• The pharmacist carries out a regular clinical pharmacy review where medication charts are clinically assessed and any interventions are relayed to the relevant consultant psychiatrist and registrar

• The pharmacist develops new patient-centred guidelines for use on the PICU e.g. Guidelines on the pharmacological prevention and management of violence or aggressive behaviour

What next?

By having an awareness of the patient experience of their medicine (especially side-effects) through regular contact at the medicines information groups, the pharmacist is in a position to provide more informed clinical advice to the PICU team. This patient-centred approach to the clinical pharmacy service could be transferred to any healthcare setting where the pharmacist can link directly with both patients and their multidisciplinary team.