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Reducing hospital pharmacies’ carbon emissions by distributing fewer metered dose Inhalers

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European Statement

Selection, Procurement and Distribution

Author(s)

Anna Harjans, Dominic Störzinger, Torsten Hoppe-Tichy

Why was it done?

Nowadays, norflurane is often used as MDIs’ propellant. It has a Global Warming Potential (GWP) 1,430 times higher than CO2. Therefore, MDIs cause larger emissions than DPIs. By lowering the numbers of MDIs in-house prescriptions, savings of emissions can be achieved.

What was done?

All Metered Dose Inhalers (MDI) of our formulary were screened for the following criteria:
– Which Active Pharmaceutical Ingredient(s) (API) are contained?
– Are comparable Direct Powder Inhalers (DPI) available?
– Can MDIs be replaced by a DPI considering wards and patients’ needs?
Distribution numbers one year before/after formulary adaptation were analysed. Furthermore, subsequent savings of greenhouse gas emissions have been calculated.
Note: Different devices cause different Carbon dioxide equivalent (CO2e) emissions because of their individual product life cycle, means that CO2e-calculations are depending on the manufacturer. Thus, it is imperative to name the exact devices in this analysis.

How was it done?

Availability of comparable DPIs with the same (combination of) API(s) and dosage for each MDI was assessed for the German market. Wards with highest orders of MDIs were identified to see who may be affected by a device change. Physicians in charge were contacted to replace MDIs where possible. Subsequently the formulary was adapted.
Saved emissions were calculated on the basis of current literature [Foster® 100/6 µg: 94.42 g CO2e/puff, Foster® NEXThaler® 100/6 µg: 7.63 g CO2e/puff (Pangione, S., et al. (2020))].

What has been achieved?

One MDI (Foster® 100/6 µg) was replaced in the formulary by an equivalent DPI (Foster® NEXThaler® 100/6 µg). Distribution numbers are shown below:

– Foster® 100/6 µg: 272 (one year pre adaptation), 4 (one year post adaptation)
– Foster® NEXThaler® 100/6 µg: 150 (one year post adaptation)

By means of this our hospital pharmacy reduced emissions by 2.921,9 kg CO2e compared to preadaptation.

What next?

MDIs containing new propellants with lower GWP are already being worked on by the pharmaceutical industry and thus, more climate friendly opposed to conventional MDIs. Replacing current MDIs with the novel, climate friendly alternatives once available on the market is a useful approach to further lower hospital pharmacies’ carbon emissions.

Rationalising prescribing of unlicensed specials to children

European Statement

Clinical Pharmacy Services

Author(s)

Helen Cooper, Sheatha Abumehdi

Why was it done?

A lack of licensed formulations for children means that use of unlicensed and off-label medicines is often the only appropriate alternative [1]. Local prescribing data demonstrates wide variability in concentrations of unlicensed specials supplied, at significant cost. This project aims to standardise medicines prescribing for children, improve patient safety by reducing inadvertent dose misadministration due to varying concentrations, reduce spend, and improve the effectiveness of working relationships between hospital and community healthcare teams.

What was done?

Prescribing and procurement data were used to analyse, review and harmonise paediatric prescribing practices in a UK clinical commissioning group, with focus on rationalising use of unlicensed specials.

How was it done?

A target list of ten medicines was identified, based on variability of strengths and formulations available, and cost. A team of two dedicated specialist paediatric hospital pharmacists was funded to set out strategies to standardise prescribing of those target medicines, and to improve understanding of prescribing and supply of unlicensed medicines to children. Various methods were used, including; email communications advertising the roles and support offered; establishing a Paediatric Formulary Group; promoting the local Paediatric Formulary; creating paediatric prescribing pathways; reviewing specials prescribing and supporting switches to alternative formulations; and delivering a paediatric prescribing webinar.

What has been achieved?

Reviews of specials prescribing were initially undertaken in two of the six boroughs in the region. 138 switches to a preferred formulation for safety and/or cost-effectiveness were identified and discussed between July-October 2021. Risks associated with prescribing multiple concentrations of liquid medicines were identified and measures were put in place to prevent patient harm. The webinar was well attended, and although it cannot be quantified, awareness of the Paediatric Formulary has improved. The project is on-going and at this time the impact on spend cannot be shown but will be reported later this year.

What next?

The specific knowledge and skills of specialist paediatric hospital pharmacists are highly valuable in driving specials medicines rationalisation for children in the community. Future plans for expanding the project include extending the service to other boroughs in the region and widening the target list of medicines.

References: 1.Rawlence E et al. Is the provision of paediatric oral liquid unlicensed medicines safe? Arch Dis Child Educ Pract Ed. 2018;103(6):310-3. 2.Neonatal and Paediatric Pharmacists Group. Position Statement 18-01 Using Standardised Strengths of Unlicensed Liquid Medicines in Children. Version 5, April 2020.

AN ITERATIVE APPROACH TO THE DEVELOPMENT OF PHARMACOLOGICAL MANAGEMENT GUIDELINES FOR THE TREATMENT OF PAEDIATRIC INFLAMMATORY MULTISYSTEM SYNDROME – TEMPORALLY ASSOCIATED WITH SARS-CoV-2

European Statement

Clinical Pharmacy Services

Author(s)

CAROL ANN JONES, NANNA CHRISTIANSEN

Why was it done?

Starting in mid-April 2020 as a result of the Coronavirus pandemic, a cluster of patients displaying multisystem inflammation and shock were admitted to our hospital. Similar cohorts have subsequently been reported internationally. Over a 6 week period, in which our institution cared for over 70 children with the newly described PIMS-TS, we developed new pharmacological treatment guidelines. Due to the novelty of the disease, treatment options were unclear and decisions were made by a multidisciplinary team (MDT) of clinicians and pharmacists.

What was done?

This good practice initiative describes the rapid and iterative development of a treatment pathway for the newly described Paediatric Inflammatory Multisystem Syndrome – Temporally associated with SARS-CoV-2 (PIMS-TS). Due to the similarity to Kawasaki disease and septic shock, the routine treatments for these conditions were considered as well as the experience of our adult colleagues, especially in terms of anticoagulation and hyper-inflammation seen in patients presenting with COVID-19. This ensured holistic management plans could be made to provide the highest quality of care.

How was it done?

A MDT of clinicians (intensivists, infectious diseases, cardiologists, rheumatologist, haematologists, endocrinologists) and pharmacists arranged daily meetings to discuss admitted patients as well as pulling together information to formulate a treatment guideline to enable the safe management of these patients. Version one of the treatment pathway was approved in April 2020, by beginning of June version 6 was published. The final treatment pathway included intravenous (IV) immunoglobulin, IV methylprednisolone, aspirin, venous thromboembolism (VTE) prophylaxis and immunomodulation therapy including tocilizumab, infliximab and anakinra.

What has been achieved?

A total of 74 patients have been successfully treated against the treatment pathway, and discharged from hospital. Managing a new condition with no published evidence on treatment was a huge challenge, especially given the large numbers and high acuity of patients. Collaborative learning and reflection has enabled us to develop a robust treatment pathway for our patients. We have witnessed MDT working at its best, united with the sole aim of combating this rare condition.

What next?

An ongoing coordinated effort is required to undertake paediatric research to understand PIMS-TS and establish the most effective treatment for this novel disease.

IMPLEMENTING A NATIONAL PORTFOLIO OF EXTEMPORANEOUS PHARMACEUTICAL PREPARATIONS USED IN DANISH HOSPITALS

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European Statement

Introductory Statements and Governance

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.

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