Pdf

Author(s)

Marinos Petrongonas, Maria Fragiadaki, Eleni Rinaki, Leonidas Tzimis

Why was it done?

HPs were facing challenges related to:
• Stuff shortages in a high risk environment with increasing uncertainty
• Implementation of Directive 2001/83/EC on Falsified Medicines; deadline for Greece is 2025
• Medicines’ shortages for which optimal inventory management procedures are needed • Patient safety and quality of pharmaceutical services: quality assurance processes, medicines’ traceability, monitoring expiration dates and respond-time to ward’s requests

What was done?

During the last 2 years, hospital pharmacists (HPs) actively participated in the supply, installation and functional integration of the first Automated (Robotic) Dispensing System (ADS) in Greece, in Chania General Hospital (CGH). It is a centralised distribution system installed in the pharmacy department which receives, stores and distributes packages of medicines.
It has a storage capacity of approximately 20,000 packages, including one robotic arm, three distribution exits, two loading ways (semi- and fully-automated), with software comprised. Speeds range from 200 to 900 for loading and 350 to 760 packages/hour for unloading. Under HPs’ direction, medicine management procedures were modified to ensure ADS’ functionality.

How was it done?

Since Pharmacy department of CGH was the first to install an ADS, a new route had to be inaugurated, concerning how HPs:
• Developed the proposal
• Documented and justified such a supply to be prioritised in funding
• Performed market research in Europe, as no such national market existed
• Drafted technical specifications, to assure the best system supplied
• Participated in an international tendering procedure (budget 130,000 euros)
• Planned and supervised installation and functional integration of the system
• Managed interoperability between ADS’ software and the pharmacy’s Information System
• Faced issues related to different barcodes on medicines’ packages

What has been achieved?

After 3 months of use:
• 50% of medicines’ codes and 35% of total packages are dispensed with ADS monthly
• 1.4 full-time pharmacy assistants equivalent is saved
• Response time to requests decreased
• Traceability and quality are better assured
• Falsified medicines’ check can run automatically
• Storage space is saved

What next?

HPs are ready to share nationally and internationally their experience in developing and installing an ADS with colleagues interested in adopting similar solutions. Hospitals from the same region have already shown their interest.

Pdf

Author(s)

Hind Bouami, Dorine Castillo

Why was it done?

The human-machine system designer has to make decisions to secure and improve the automation process, and handle organization’s complexity. Documenting human agent’s situation awareness is crucial to support human-machine designers’ decision-making. Knowledge about risks, critical parameters and factors that can impact and threaten automation system’s performance and security are valuable for human agents, and should be collected using preventive and retrospective approaches.The evaluation of Macon hospital center’s automation performance enables to identify critical parameters to control in order to secure the human-machine system.

What was done?

An automation evaluation approach has been conducted in Macon hospital center, a hospital equipped with automated drug dispensing solutions for more than 5 years. The analysis of Macon hospital center automation’s feedback provides relevant information to enhance the perception and the comprehension of the system’s complexity fully, environmental factors that interact with the system, and to identify critical parameters in the automation process. Therefore, agents can design a projection of a secure and performant automated organization. This information will enable hospitals to make effective decisions to improve their automation project performance.

How was it done?

We deployed an anthropocentric approach for automated system evaluation in Macon hospital center.
Our approach integrates six steps that are run in automated hospital pharmacies to analyze their feedback [6]:
1) The identification of pharmacy’s automation needs and objectives, and the analysis of operational environment and existing equipment,
2) The analysis of automated equipment functional specifications formalized by the pharmacy,
3) The evaluation of automation deployment results and related gains,
4) The evaluation of specific actions implemented by the pharmacy during automation process,
5) The analysis of the parameters to control for automated equipment integration security and performance,
6) The analysis of factors influencing human-machine interaction.

What has been achieved?

The analysis of Macon hospital center pharmacy’s automation specifications revealed that 66.22% of automation requirements are technical, 29.73% concern human-machine interaction, and 4.05% relate to human aspects.
80.95% of automation specification related to the chosen Sinteco’s automated solution are met. The performance of the chosen automated solution is involved in 28.38% of automation specifications performance in Macon hospital center. The remaining systemic parameters involved in automation specifications performance need to be controlled.
Critical systemic parameters involved in automated solutions specifications and performance that have been identified through Macon hospital’s automation feedback are: the specificities of the chosen automated solution, hospital’s strategic decisions and budgetary constraints, the complexity of the hospital’s organization, the complexity of hospital’s information system, the constraints related to the packaging of drugs by pharmaceutical firms, users training, the complexity of the automated system, and users’ requirements and constraints.
The five parameters influencing human-machine interaction that should be managed to secure automated systems are: understanding the system’s complexity, defining relevant levels of automation, determining human and automated agents’ authority, determining human and automated agents’ autonomy, and understanding the human complexity.

What next?

Handling life-critical systems complexity such as medication delivery activity requires to be equipped with appropriate technology, and to control automation risks. The integration of human-machine principles is crucial to secure automation in hospitals, and to maintain a good balance between automation and human skills.

Why was it done?

The aim of the study is to assess the crisis impact on the consumption of pharmaceutical products in the intensive care unit in order to estimate, rationalize the need and prevent supply problems.

What was done?

Due to Covid-19 pandemic and its major economic impact, we carried out a comparative study of the consumption of pharmaceutical products in the intensive care unit before and during the crisis.

How was it done?

A list of pharmaceutical products to be evaluated has been established beforehand. The choice was made for the products most used in intensive care units in accordance with the recommendations of COVID management. The list includes drugs and medical devices.
In order to compare the consumption of these products in terms of quantity and cost, data collection was carried out over two periods, each of 6 months, before and during the crisis in Tunisia. The first from January 1st, 2019 to June 30th, 2019, the second from January 1st, 2021 to June 30th, 2021.

What has been achieved?

As a result of this assessment, it was possible to quantify the increase in several drugs and medical devices. It led us to:
-modulate our supply of these products
-take rationalization measures in cooperation with doctors
-develop management protocols according to the recommendations and available products
– close monitoring of prescriptions and compliance with protocols in order to optimize consumption, avoid any abuse and limit breaks as much as possible.

Tab. Variation of consumption and cost

Product Consumption2019 Consumption2021 Variation factor of the consumption Variation factor of the cost
Hypnotic curares 25 170 6.8 8.1
Antithrombotics 647 2286 3.5 8.1
Antibiotics 932 4060 4.4 11.2
Fluconazole 240 378 1.6 1.9
Dexamethasone 845 1268 1.5 2.0
Isolation gown 740 6925 9.4 7.8
Masks 6100 13300 2.2 2.2
hydroalcoholic products 123 217 1.8 1.8

What next?

A generalization of the drafting and updating of the protocols concerning the management and the dispensing is programmed for all the other departments which will be validated by the therapeutic committee and the antibiotics committee.

Author(s)

PATRICIA ORTIZ FERNANDEZ, Alba Maria Martinez Soto, PILAR FERNANDEZ-VILLACAÑAS FERNANDEZ

Why was it done?

1.Reduce the stocks of drugs in the medicine cabinets of the hospitalization units (HU). 2. Adapt scheduled drugs dispensing to those of preparation and administration at the HU. 3. Reduce the number of returns of dispensed drugs, as the main indicator of improved efficiency.

What was done?

Optimize the drug distribution circuits within the hospital, adapting them to the changes produced in the organization to increase the quality and efficiency of the drug use process.

How was it done?

1. Constitute an improvement group (pharmacy service (PS), supervisors oh HU and nursing address.
2. Define and propose stock agreements by the PS
3. Call meetings to review the agreement and circuit of drug dispensing
4. Incorporation of agreements in the corporate program and implementation of the agreed circuit changes.
5. Publish the updated drug distribution circuit
6. Restructuring of medicine cabinets
7. Evaluation of indicators: a) Decrease types and amounts of drugs in HU. b) Decrease in drug returns of drugs to PS

What has been achieved?

A total of 6 meetings have been held, reaching the following agreements:
1. Mantain a reduced stock of drugs in the HU
2. Establishment of the medicine cabinets agreements for the 14 HU.
3. Limitation of request for medication by stock. Ant other request will be made individually for each patient.
4. Circuit changes:
a. Partial modification of the medication dispensing schedule in the unit dose dispensing system
b. Streamlining the comunication system between the pharmacy service and hospitalization units.
c. Dispatch of medication dispensed in patient transfers
d. Establishment of criteria for urgent requests
5. Written dissemination of the changes to all pharmacy and nursing staff

What next?

Quality indicators will be avaluated 6 months after implementation.
We hope to avoid ineficiencias derived from the existencce of double circuits and to optimaze the control and preservation of drugs in the HU
The establishes drugs is not static, modifications are posible.

Author(s)

Elena Bazzoni, Roberto Pane, Claudia Montanari, Giulia Rocca, Camilla Ercoli, Maurice Oriente De Ponzio, Thérèse Gregori, Simonetta Radici

Why was it done?

Piacenza is one of the most hardly hit cities in Italy during the first wave of COVID-19. Due to the severe impact that this pandemic had in the area, hospitals were saturated with patients with respiratory failure. We thus needed to rapidly set strategies that allowed a fast dismissal of patients from the hospital without interrupting their oxygen therapies or avoid their hospitalization in case of mild respiratory failure.

What was done?

Starting from COVID-19 pandemic, our pharmaceutical unit cooperated with medical doctors of the area to allow home-delivery of oxygen therapies and grant continuity between hospital and territory. We thus developed a structured system that allowed fast activation, efficient tracking, prompt variations, and dismissal of patients from oxygen therapies at their house.

How was it done?

Since February 2020, all the oxygen therapy prescriptions from the hospital and the territory converged to the pharmaceutical service. In collaboration with the pneumology unit, we set up a database collecting patient generalities who needed oxygen therapy to grant the proper follow-up during the pandemic. In April 2020 the database was shared also with medical doctors belonging to the newly formed Special Unit for Assistential Continuity (USCA). This team was in charge of visiting patients at their houses. In collaboration with USCA and the IT service, we developed a web-based system that allowed real-time communication between Pharmacy, USCA teams, and some hospital units granting the continuity between hospital and territory.

What has been achieved?

From the beginning of the pandemic, the pharmaceutical unit has handled more than 960 requests of oxygen therapies regarding more than 900 patients. Our database is updated with all of the patients granting the tracking of each one of them as well as the therapies assigned. Our system also allowed USCA to follow patients on the territory reducing the pressure on hospitals. In 2020, indeed, more than 75% of oxygen prescriptions were requested by hospital units while in 2021, 81% of them came from USCA and territorial units.

What next?

Our currents efforts aim to reduce procedural complexity to grant access to pharmacological therapies. This new web-based system represents, indeed, an versatile and key tool to reach our goal. We are currently extending its use to the whole hospital for oxygen therapies independently of the underlying pathologies. This will allow an easy and complete transfer of these therapies on the territory. Moreover, we are implementing the possibility to prescribe drug-based pharmacological therapies in an in-home context.

Author(s)

LUCÍA SOPENA, VICENTE GIMENO, OLGA PEREIRA, Mª ANGELES ALLENDE, RAQUEL FRESQUET, RAQUEL GRACIA, BEATRIZ BONAGA, MERCEDES ARENERE, TRÁNSITO SALVADOR, ALBERTO FRUTOS

Why was it done?

The growing technological development of pharmacy services involves the coexistence of traditional warehouses with automated medicine dispensing systems controlled by different computer programs. The information was splitted into different systems and databases giving rise to possible errors due to the greater complexity.
This is a threat but also an opportunity for the hospital pharmacist to lead the development, review, and improvement of medicine use processes and the use of health technologies.
KNIME data analysis covered the need of our Pharmacy Service to blend data from any source in a single file simplifying the process.

What was done?

The Pharmacy Service of a tertiary-level hospital has implemented Konstanz Information Miner (KNIME) data analysis and treatment program to optimize the stock management of several medicines.

How was it done?

An initial algorithm was designed by the union of 7 files and can be executed at any time to obtain the updated data.

What has been achieved?

This file provides up-to-date information about the stocks, stock-outs, consumptions, orders and purchasing data of all medicines (average price, laboratory, date and number of orders, units to be received).
In addition, KNIME calculated the coverage time from consumption, and the current stock in the warehouses, obtaining a global vision of highest turnaround pharmaceuticals drugs.
The program also allows linking and merging data of the list for shortages of medicines, supply disruptions and restocking time provided by the Spanish Agency of Medicines and Medical Devices (AEMPS).
KNIME program has been especially important in our Pharmacy Service during the pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Big data analysis has allowed the hospital pharmacist to anticipate missing specialties and to make a rapid response in ensuring the availability of Essential Medicines List (EML) composed by 75 proposed by AEMPS and 138 by our hospital (e.g. antiinfectives, analgesics, muscle relaxants, anesthetics).

What next?

KNIME is a tool that could be successfully implemented and appropriately generalized as recommended to all Pharmacy Services that use different data sources, and want to have a generalized view of the information.
KNIME represents an advance in the stock and stockpiling management of medicines specialties to work more efficiently, which improve patient care and safety.

Author(s)

Emma Pinet, Lionel Barty, Anne Blandine Bouvrain, Françoise Le Cheviller, Nicolas Vaillant, Nathalie Jourdan, Hélène Sauvageon, Isabelle Madelaine

Why was it done?

In order to make hospital preparations in advance and optimize costs, a physicochemical and biological stability study was conducted in the pharmaceutical control laboratory.

What was done?

Mogamulizumab is a monoclonal antibody used in the treatment of Sezary syndrome and mycosis fungoides. The dilution of the 4 mg/ml vial of Poteligeo® in the infusion bag is stable for 24 hours at room temperature between 0.1 to 3 mg/ml.

How was it done?

Four bags of mogamulizumab were prepared in 0.9% NaCl 250 ml (2 at 0.14 mg/ml, 2 at 0.34 mg/ml). Each dilution is evaluated at 20±5°C and at 5±3°C, protected from light for 28 days. Analyses are performed in triplicate by High Performance Liquid Chromatography (HPLC-UV) associated with Chromeleon™ software. Concentrations are measured by HPLC after Flow Injection Analysis (FIA). Physical stability is studied by searching for IgG aggregates by Steric Exclusion Chromatography (Biozen™SEC3 column, 1.8µm 300*4.6mm). Chemical stability is evaluated by assessing acidic and basic variants proportions of the antibody by Cation Exchange Chromatography (CEC) (Biozen™WCX column, 6µm 250*4.6mm). Biological activity is determined by evaluation of the different glycoforms, by affinity chromatography (FcyRIIIa column, 5µm 75*4.6mm Tosoh®). The microbiological stability is performed by seeding the diluted solution on chocolate agar and brain heart broth.

What has been achieved?

At D28, the quantitative determination of mogamulizumab by FIA showed a deviation of less than 10% compared to theoretical concentrations. No aggregates or antibody fragments were found. The proportion of acidic, basic variants and of the main peak did not deviate by more than 5% compared to D0. For all infusion-bags studied by CEC, the main peak rates were between 79.1% and 85.8%, the acidic variant rates between 6.7% and 9.9% and the basic variant rates between 7.8% and 11.2%. The proportion of each antibody species (low, medium, high affinity) did not deviate by 5% from D0. The low affinity rate is between 48.2% and 52.7%, medium between 39.6% and 44.8% and high between 6.9% and 7.9%. No colonies were found on chocolate agar and heart-brain broth.

What next?

Mogamulizumab is physically, chemically and biologically stable for 28 days in diluted solution between 0.14 mg/L and 0.41 mg/L at 5°C and 20°C.

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.

Author(s)

María Molinero, Virginia Puebla, Cristina González, Lidia Ybáñez, Gonzalo Hernando, Natalia Sánchez-Ocaña, Javier Corazón, María de la Torre, Jose Manuel Martínez

Why was it done?

This technique provides autonomy to the patient allowing to adjust the dose based on the intensity of pain. It has been demonstrated that small on-demand doses of analgesia provide a reduction in the final dose, thus reducing side effects. In addition, by minimizing the possible delay in the administration of analgesia, the anxiety associated with pain and exacerbations is reduced.

What was done?

Hospital Pharmacy Service in collaboration with Acute Pain Unit has developed a protocol for an analgesic mixture for intravenous administration in continuous infusion based on tramadol, dexketoprofen and haloperidol. It is a patient-controlled analgesia (PCA) administered by pump for the treatment of acute postoperative pain.

How was it done?

We performed a bibliographic search of stability studies in order to standardize the analgesic mixture, guaranteeing its physical-chemical and microbiological stability.

What has been achieved?

A mixture of 600mg tramadol, 300mg dexketoprofen and 5mg haloperidol was prepared and it was filtered through a 5-micron filter. It was diluted in 100mL of 0.9% sodium chloride, obtaining a mixture of 125mL. It was sealed and bagged in a photoprotective bag. After the bibliographic search on stability data and physical-chemical compatibility of the mixture, a stability of 14 days at 2-8 ºC was established. Once elaborated, quality control was performed by gravimetry. It was dispensed weekly by stock to the post-anesthesia resuscitation unit. The established perfusion rate is 1.3 mL/h or 1.7 mL/h for 48h. With each rescue, 8mg of tramadol and 4mg of dexketoprofen are released per hour or 4mg and 2mg every 30min, respectively. The maximum dose that can be administered is 400mg tramadol, 150mg dexketoprofen and 2mg haloperidol, except if the patient weighs less than 50kg: 8mg/kg tramadol. If renal insufficiency, dose adjustment was mandatory.

What next?

The centralization of the preparation of intravenous admixtures from the pharmacy service allow us to adjust the expiry date based on stability studies reported in the literature, to maintain the asepsis of the mixture as it is prepared in horizontal laminar flow cabinets, to increase the safety and to secure the traceability.

Author(s)

Louise Refsgaard, Linda Skovsted, Nina Bøggild

Why was it done?

The medical supply vending machines were implemented during 2021 as a way of direct-to-patient distribution of medicine with more flexibility. The aim was to offer 24-hour access to collect medicine at a location that suits the patient, e.g. close to the patient’s home.

What was done?

Medical supply vending machines were implemented in the Capital Region of Denmark. The vending machines allow patients to collect their medicine whenever and wherever it suits them. It is the patient’s healthcare professional that controls and orders the medicine. The hospital pharmacy staff consults the prescription and labels, dispenses and records the medicine and places it in the vending machine for collection.
Patient and staff satisfaction was surveyed.

How was it done?

The implementation of this new direct-to-patient distribution method was carried out by the Capital Region Hospital Pharmacy in close collaboration with the region’s hospitals and outpatient departments. Installing the machines was fast but a full implementation requires that the clinical staff rethink their practice and accept that dispensing is no longer their responsibility. This has been the biggest obstacle along with creating patient safe procedures.

What has been achieved?

7 medical supply vending machines were installed centrally in hospitals in the Capital Region of Denmark. The machines are now used to distribute medicine to some of the region’s outpatients.
The patient satisfaction survey showed that the patients are very satisfied with the vending machines: 100 % are either ‘highly satisfied’ (86 %) or ‘satisfied’ (14 %) with the new service, and 97 % would like to use it again. The staff was also satisfied with the new service.
Additionally, the quality of medicine dispensing is increased due to hospital pharmacy staff dispensing the medicine rather than nurses.

What next?

In order to offer flexibility to patients and increase the quality of dispensing of medicine, we aim to increase the number of patients that collect their medicine from the vending machines by using the current machines in their full capacity and installing more machines. We also aim to collaborate with Denmark’s other 4 regions, so that patients, who are treated outside their home region, can collect their medicine in a vending machine closer to their home.