Implementation of a telepharmacy service in outpatient’s pharmaceutical consultation
European Statement
Clinical Pharmacy Services
Author(s)
QUERALT LOPEZ NOGUERA, ÀNGELA CASTELLÓ NÒRIA, CRISTINA DIEZ VALLEJO, LAURA VIÑAS SAGUÉ, MARTA COMA PUNSET, SILVIA CABARROCAS DURAN, MIREIA VILA CURRIUS, ANNA DORDÀ BENITO, EDUARDO TEJEDOR TEJADA, CRISTINA TORO BLANCH, ROSA NURIA ALEIXANDRE CERAROLS, ROSA SACREST GÜELL
Why was it done?
The declaration of the state of emergency by SARS-CoV-2 pandemic on March of 2020 had an impact on hospital PC.
During that period, it was advised by Healthcare Authorisations to minimize the risk of infection or spread of SARS-CoV-2 in order to protect vulnerable groups. For that reason, it was not recommended to assist in the hospital if it was not necessary. This fact caused some organizational changes in OPC to adapt to the current situation.
What was done?
Our hospital Pharmacy Department created a telepharmacy service in outpatient’s pharmaceutical consultation (OPC) after state of emergency declaration by SARS-CoV-2. We created a standard operating procedure working together with communitarian pharmacists and the Region Pharmacist’s College. The main aim was to ensure pharmaceutical care (PC) quality in vulnerable patients and the correct medication distribution and conservation. Pharmaceutical care was developed by telephone call and medication was send to communitarian pharmacy.
A comprehensive analysis was made to concern the impact on drugs delivery selecting certified distribution company which ensured drug traceability, custody and conservation.
How was it done?
In 2020, approximately 60 patients per day used to attend in OPC. According to the large number of patients, we defined which patients could take advantage of this programme. The selection criteria were adherent patients with pulmonary pathologies (cystic fibrosis, asthma, bronchiectasis, etc.), multiple sclerosis, amyotrophic lateral sclerosis, reduced mobility or patients over 65 years old who lived in more than 30km closed to the hospital or without any family member that could come.
In order to ensure the process traceability, an informatics tool has been created by Region Pharmacist’s College. Pharmacy Department, community pharmacy and the distribution company assumed all expenses.
What has been achieved?
369 of 2.346 patients were included in our telepharmacy service during the state of emergency. There was high level of acceptance by all patients. Only low-risk patients or patients who had an on-site doctor visit were attends in OPC. Nowadays, 196 patients still benefit from the initiative.
What next?
Telepharmacy program avoids patient’s displacements that are particularly susceptible to COVID-19 negatives effects. Moreover, it guarantees PC quality, patient’s adherence, process traceability and correct medication conservation from hospital to patient’s home.
Do we provide patients with sufficient information for the safe use of thermolabile medicines?
European Statement
Clinical Pharmacy Services
Author(s)
Miguel Angel Carvajal-Sanchez, Josefa Leon-Villar, Pilar Pacheco-Lopez, Javier Ibañez-Caturla, Paula Torrano-Belmonte, Lydia Fructuoso-Gonzalez, Juan Antonio Gutierrez-Sanchez, Maria Hernandez-Sanchez
Why was it done?
In recent years, we have witnessed a significant increase in the number of thermolabile pharmaceutical specialities, which makes it necessary to keep strict control of the storage temperature from manufacture to administration.
In this context, patient education is a fundamental step in ensuring that these medicines are administered effectively and safely.
What was done?
A study was carried out to determine the quality of the information provided by Hospital Pharmacy Service (HPS) professionals to patients regarding the storage of thermolabile medicines (TM) at home.
After analysing the variability of the results, we established in a protocolised manner the necessary and sufficient information items to be included in the pharmaceutical advice to patients regarding the storage of this type of medicines.
How was it done?
A random selection of 28 HPS professionals (13 nurses, 10 specialist pharmacists and 5 resident pharmacists) was made. Each participant, in isolation and individually, made a selection of criteria to be contained in the patient information regarding the transport and storage of TM.
The results obtained were:
General information:
o Informing that it is a TM: 89.28%.
o Telephone number for incidents: 10.71%.
o Keep out of the reach of children: 3.57%.
o Return if discontinuation of treatment: 3.57%.
Storage:
o Specify location in refrigerator: door/indoor distinction 28.57%; Avoid contact with walls: 28.57%; specific place in refrigerator 3.57%.
o Do not store next to food: 17.85%.
o Refrigerator/freezer distinction: 10.71%.
Transport:
o Recommendations for correct transport: 50%.
o Time elapsed from dispensing to refrigerator storage: 39.29%.
Administration:
o Tempering prior to administration (when necessary): 39.28%.
o Visual inspection: 7.14%.
o Check expiry date: 7.14%.
o Frecuency of administration: 3.57%.
What has been achieved?
Completion, standardisation and systematisation of the provision of information to patients on TM.
What next?
Training sessions will be given to all HPS professionals involved, including new recruits and pharmacy assistants. This is an initiative applicable to all HPS.
EXPANDING OPPORTUNITIES FOR PHARMACISTS IN ONCO-HEMATOLOGIC CLINICAL TRIALS: DESIGN AND IMPLEMENTATION OF THE OUTPATIENT SERVICE MODEL
European Statement
Clinical Pharmacy Services
Author(s)
Eugenia Serramontmany Morante, Patricia Garcia Ortega, Lorena Garcia Basas, Pablo Latorre Garcia, Pilar Rovira Torres, Laura Maños Pujol, Isabel Cidoncha Muñoz, M. Queralt Gorgas Torner
Why was it done?
The provision of outpatient oncology services by pharmacists is still limited, but it is an emerging role. It can add value while increasing the quality of patient care required, maximizing the likelihood of achieving positive outcomes and thus improving the patient’s quality of life. It is important to incorporate clinical pharmacists into outpatient clinics to ensure the safe use of investigational drugs and guarantee the best treatment for the patient.
What was done?
The oncology clinical trials pharmacy team initiated an outpatient clinic at a tertiary hospital. This enabled review of patients’ medications, monitoring of interactions, appropriate oral chemotherapy counseling, design of medication diaries and instructions, discussion of side effects, as well as other dietary and daily living recommendations.
How was it done?
A multidisciplinary team was formed: pharmacy, medical, nursing, ancillary and administrative staff, to discuss circuits and strategies to address outpatient pharmacy clinic.
The pharmaceutical care program was implemented gradually during 6 months, first in phase I, then phases II and III clinical trials.
Factors including appointment scheduling, patient prioritization, clinic room availability as well as detailed definition of pharmaceutical activity were discussed, in order to have a standard procedure for all patients included in a clinical trial.
The group continued to meet weekly to further discuss the progress of the pharmaceutical care program and any obstacles and unforeseen events.
What has been achieved?
Medication has been dispensed to 8447 patients in the outpatient pharmacy, of which 1172 patients have been attended by the clinical pharmacist during the first 8 months (January-August 2021) of the programme’s implementation.
Pharmaceutical care at the first day of treatment has been provided to 275 patients to explain how to take the treatment and resolve doubts. The concomitant medication of 312 patients has been reviewed for the screening and 425 telephone queries about concomitant medication have been resolved.
What next?
The evolutionary change in cancer care along with the increase in the number of clinical trials and its complexity will emphasize the need to include the oncology pharmacist in the cancer care team. The role of a clinical pharmacist is vital to ensure the safety and controlled use of the drug, ensuring the best possible outcomes.
Croatian hospital pharmacists managing earthquake(s) medical consequences during lockdown(s)
European Statement
Clinical Pharmacy Services
Author(s)
Mirna Momcilovic, Anita Simic, Petra Turcic
Why was it done?
Croatia was hit by 2 big earthquakes in 2020, both happened just right after 1st and 2nd lockdown due to high number of COVID-19 cases. Since most of the hospitals were strategically built on the hills, it was more destructive for them. It also hit a number of community pharmacies responsible for drugs supply to specific areas in the country. There was no electricity, no heating, no drugs supply, no fridge to store drugs, for days, so quick back-up plan was needed to provide minimal healthcare.
What was done?
Croatian hospital pharmacists organised a temporary pharmacy in a tent, filled it with drugs and medical products donated from community pharmacies, hospitals and wholesalers from Croatia and other European countries and started supplying patients with it.
How was it done?
It was modified way of dispensing, without prescription because there was no doctors and no place to prescribe it, based on patient’s medical documentation, if available, and patient’s medication history according to what patient said only. Pharmacists needed to use their knowledge about dosing, duration of action – difference between immediate release or modified release formulations, possibility of splitting tablets into equal parts to get the needed dose and, most important, substituting drugs from the same pharmacologic class (ex. switching from one inhaler for treatment of asthma containing ICS + LABA to another one that was available at the moment), taking into consideration patient’s needs and avoiding drug to drug interactions. Pharmacists provided patients with OTC drugs, free of charge, followed by an advice of how to use it. Non having prescription problem was solved afterwards by Croatian Health Insurance Fund. Also, all the supply of vaccine against COVID-19 available in Croatia at that point, was sent to an area hit by the earthquake. Vaccination was done by doctors, and pharmacists assisted by supplying them with all the equipment needed (needles, alcohol, cotton wool, etc.).
What has been achieved?
Patients were supplied by all the drugs/medical products needed in the first, critical week after an earthquake.
What next?
Following the Croatian example of handling an earthquake situation, there is an idea of organising a medical crisis team, would include pharmacist, in each European country.
Parenteral Nutrition Waste Reduction Initiative
European Statement
Selection, Procurement and Distribution
Author(s)
Marie O Halloran, Siobhán Nestor
Why was it done?
This project was undertaken in reaction to an evolving healthcare environment. It was important to identify patterns to improve the efficiency of the purchasing and dispensing process, and to ensure that PN levels held in the Pharmacy Department respond to requested use within the hospital. The aim was to reduce the amount of PN bags expiring with associated cost savings and waste avoidance.
What was done?
The Pharmacy Department is responsible for dispensing Parenteral Nutrition (PN) in the Mater Misericordiae University Hospital (MMUH). PN is purchased from a third party manufacturer. On receipt by the hospital, the standard PN bag has an expiry date of approximately 60 days. Given the need for rapid turnover of PN to avoid expiration and wastage, coupled with the rapidly changing healthcare landscape, the pharmacy instigated a review of the factors contributing to PN waste and opportunities to improve and optimise the associated processes.
How was it done?
• PN Stock Holding Review
Due to surgery volumes and the complexity of the patient cohort in MMUH, the Pharmacy Department are required to hold a stock of PN bags for patients to access in a timely manner. The agreed levels of stock held was identified as a key target to reduce waste. The quantity of each stock bag held was reviewed between Pharmacy and Clinical Dietetics utilising recent usage pattern reports. This resulted in removing certain bags from MMUH stock entirely and reducing the stock quantity of slow-moving bags.
• Improved communication to dietitians
A standard email template was devised to send to all stakeholders, by a Dispensary Pharmacist, detailing the stock of each bag on hand and highlighting bags which would expire in the following two weeks. The Dietitians endeavour to utilise this short-dated stock for suitable patients to avoid waste.
What has been achieved?
Through the improvement initiatives outlined above, PN waste reduced by 74% (117 bags versus 31 bags) in Q1-Q3 2021, compared to the same period in 2020. This resulted in a considerable associated cost saving.
What next?
We will continue our collaborative work with Clinical Dietetics to further reduce PN waste. We now have a dynamic stock management process, which responds to the changing patient cohort in MMUH.
IMPLEMENTATION OF A TELEPHARMACY PROGRAMME TO HOSPITAL OUTPATIENTS DURING THE COVID-19 PANDEMIC
Pdf
European Statement
Selection, Procurement and Distribution
Author(s)
Rosalia Fernández-Caballero, Virginia Collados Arroyo, Clara Herranz Muñoz, Araceli Henares López
Why was it done?
Every month, an average of 700 patients receive pharmaceutical care in the outpatient consultation (OC) of our first-level hospital. Given the mobility restriction measures applied by the spanish government during the pandemic, access to this consultation was difficult for some patients. The aim of this program is to ensure the access to medication for all patients and prevent them and professionals to virus exposure. Telepharmacy program consists of providing pharmaceutical care based on available means of communication and access to medication through home drug delivery.
What was done?
During the COVID-19 pandemic, we designed and implemented a telepharmacy programm to ensure access to medication for all patients.
How was it done?
Once weekly, the pharmacist contacted the listed patients during the following week in OC by telephone or via the hospital’s electronic platform, to offer the possibility of participating in the program. During teleconsultation, pharmacist provided the same attention as in face-to face consultation: administrative situation of the patient, adequate medical follow-up, assessment of adherence, review of interactions and adverse events and treatment changes. Moreover, we e-mailed the patient’s consent for home drug delivery by and external company. In case the patient didn’t have a web mail, we requested verbal consent. Once a week, one pharmacy technician prepared the medication and the selected company performed the home delivery in guaranteed storage conditions. To minimize the burden of work, the medication was sent for two months per patient. Oncohematological patients, who came to their doctor’s appointment every month, were excluded from this program.
What has been achieved?
Between March 20 and October 9, we have included 595 patients in this program and conducted 1190 teleconsultations and 872 home drug deliveries with a great satisfaction of outpatients.
What next?
Our next step is to improve the web system for sending alerts through our electronic platform to automate the home delivery process and thereby to reduce the logistic burden of the pharmacist and to increase the pharmaceutical care given to patients.
DESIGN AND IMPLEMENTATION OF A TELEPHARMACY PROTOCOL IN A THIRD LEVEL HOSPITAL DURING THE CORONAVIRUS PANDEMIC
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
YLENIA JIMÉNEZ LÓPEZ, MARIA ISABEL SIERRA TORRES, ENCARNACIÓN PÉREZ CANO, JUAN JEREZ ROJAS, CARMEN LUCÍA MUÑOZ CID, RAQUEL CLARAMUNT GARCÍA
Why was it done?
After the declaration of the national state of alarm due to the COVID-19 crisis, the Outpatients Pharmaceutical Care Unit detected the need to design a telepharmacy protocol.
This protocol was established with the aim of avoiding patient vistis to PS, thus reducing the risk of outbreaks originated in the hospital.
Since March 19, 2020, the protocol has been implemented with no interruption.
What was done?
Due to SARS-CoV-2 pandemic situation, we developed a telepharmacy protocol for the outpatients of a Pharmacy Service (PS).
How was it done?
Circuit and stages:
1. Selecting patients candidates for telepharmacy, who were those with an appointment for collecting medication in the PS and had no other appointment within the hospital (with the doctor or for treatment administration).
2. Contacting with the patient or the caregiver via telephone to verify treatment adherence and the delivery data and place.
3. Packaging, highlighting the correct identification data and storage conditions.
4. Notifying to the delivery company.
This protocol was agreed by the PS, the hospital management and physicians involved.
The system was designed, in the first place, so that treatments were delivered by courier service to the patients’ addresses. Finally, due to logistic and economic problems, it was modified to make delivery through pharmacy offices (PO).
What has been achieved?
6.068 treatments have been delivered from 19/03/2020 to 30/09/2020: an average of 47 shipments per day.
In the 6068 shipments, there have been:
• 722 (11,9%) delivered through an external company (19 / 3-20 / 4/20)
• 756 (12,5%) delivered by the local courier (19 / 3-29 / 4/20)
• 4590 (75,6%) delivered through PO (8 / 4-30 / 9/20)
During this whole period, 14.496 patients (including telepharmacy) have been attended in the PS. The 6.068 deliveries mean that we have avoided 42% of hospital visits, thus minimizing the risk related to the pandemic.
The change in the delivery system has meant a cost reduction from 10.000 €/month with the first system to 0 €/month with the pharmacy office system.
What next?
Our telepharmacy protocol is still active. We keep working on ways to improve the communication with patients and increase the number of telecare services.
DRUG SERIALISATION: ORGANIZATIONAL AND ECONOMICAL IMPACTS FOR HOSPITAL PHARMACIES (submitted in 2019)
Pdf
European Statement
Selection, Procurement and Distribution
Author(s)
Quentin HIVER, Agathe ROGER, Marine EGOT, Ivan VELLA, Marie-Hélène TYWONIUK
Why was it done?
Community and hospital pharmacists are required to apply the European directive on falsified medicines. In France, we are currently undergoing a transition phase for the progressive generalisation of serialisation. French pharmacies are more or less ahead of schedule for the implementation of decommissioning. In our pharmacy, the decommissioning has been operational since February 2019. After 8 months of practice, we are able to provide data as a basis for work and thinking.
What was done?
Determining and evaluating, by feedback approach, the organisational and economical impacts of drug serialisation for a hospital pharmacy
How was it done?
• Step-by-step description of the supply chain after implementation of decommissioning. • Collection of the man-hours necessary for: decommissioning implementation, software training, routine decommissioning, problem solving. • Census of financial investments
What has been achieved?
After analysis of our supply chain, the reception stage appeared to be the most favorable for decommissioning, in terms of practicality, safety and traceability. Several steps have thus been added at reception: Identification of serialized boxes, manual scan, checking of the decommissioning report and the number of decommissioned boxes, printing of the report. The pharmaceutical time necessary for the decommissioning implementation has been estimated to up to 28 hours. The software training was made in small groups of 2−3 agents, requiring 9 minutes per agent on average. The decommissioning is currently requiring 17 minutes for 100 boxes. Over 8 months, the time necessary for the pharmacists to solve problems linked with serialisation (non-operational Hub, corrupted database, error message at decommissioning…) was estimated to up to 7 hours. The financial investment amounts to 17200 euros (software+ergonomic desk+man-hours at implementation).
What next?
The decommissioning itself doesn’t have a major impact on the pharmacy’s organization. But, ensuring a clear and safe supply chain, to identify which boxes must be decommissioned and which boxes can be dispensed, is time-consuming. It goes through a proper working environment with a forward supply chain and traceability tools. Moreover, the encountered problems were mainly due to computer failures, requiring a performing software with an efficient maintenance. We are currently working on improving the ergonomics of the workstation to avoid the risk of musculoskeletal disorders due to decommissioning.
A ROBUST LEAN METHOD FOR IMPROVING THE MEDICATION MANAGEMENT PROCESS
European Statement
Patient Safety and Quality Assurance
Why was it done?
Hospitals are facing strong economic constraints and increasing requirements in terms of quality and safety of care. To address these difficulties, a solution could be to reorganise processes and relocate resources through the use of industrial engineering Business Process Improvement approaches such as Lean.
What was done?
An original Lean method for business process improvement was designed and tested in an acute general medicine department in order to improve the mediation management process.
How was it done?
A Lean method for the hospital setting was elaborated based on a triangulation between literature data, semi-structured interviews and a case study. This method, relies on 5 operational activities (Understand the process, Measure, Analyse, Improve, Implement) and 6 support activities (Establish top management support, understand the environment, Organize a project team, Manage change, Monitor and continuously improve). A multidisciplinary project team (nurses, head nurses, pharmacists, physicians, pharmacy technicians, nurse’s aide) was then formed to experiment this method in the acute general medicine ward.
What has been achieved?
This project allowed improving the efficiency and quality of the medication management process. Medication errors at admission and risk for medication errors during administration were reduced (46% vs 12%), non -value added activities during administration were eliminated (25 minutes/nurse/day saved), ward stock management was streamlined (double bin system) and medication delivery was secured. More than 80% of the stakeholders surveyed (45) considered that the changes made to the process improved their working conditions (no impact for the others) and all the participants to the project team were satisfied or very satisfied with the project. The team now meets once a month to continuously improve the process.
What next?
The top management of the hospital has decided to promote this method and is currently creating and training a specific improvement team to support other improvement projects in the hospital.