DRUG-FOOD INTERACTION GUIDE PREPARATION FOR OUTPATIENT CONSULTATION
European Statement
Patient Safety and Quality Assurance
Author(s)
Gregorio Romero Candel, Paula Ruiz Belda, Carmen Caballero Requejo, Maria Jesus Sanchez Cuenca, Jose Marco del Rio, Juilan Castillo Sanchez, Luna Carratala Herrera
Why was it done?
Some drugs dispensed in the outpatient office present interactions with food, leading to changes in their bioavailability. These changes which can result in a decrease in therapeutic activity or an increase in adverse effects, when dealing with narrow therapeutic margin drugs, may lead to alterations in their efficacy and/or toxicity. Developing the quick and accessible consultation table, we improved the quality and effectiveness of the treatment.
What was done?
Preparation of the drug and food interaction guide for outpatient consultations.
How was it done?
The technical specifications of all drugs that are dispensed in the hospital outpatient office were consulted, and the possible interactions with food of every one of them were analysed by consulting the following electronic databases: Technical sheet, Bot Plus, Micromedex, Pubmed, UpToDate and Online Medicine Information Centre of the AEMPS. A database was developed with drugs that presented some type of restriction with meals, designing a quick reference table for outpatient consultation.
What has been achieved?
One-hundred specialities were reviewed, of which 22 were to be taken without food, 43 with food and 35 could be taken with or without food. The information given to the patient was quick and efficient, improving the effectiveness and safety of the treatment.
What next?
Our goal is to continue developing tools that allow us to provide quality information to the patient, improving the effectiveness and safety of treatments.
PROGRAMME OF PHARMACOTHERAPEUTIC BENEFIT TO THE SOCIO-SANITARY CENTRES OF A SPECIFIC HEALTH AREA THROUGH THE HOSPITAL PHARMACY SERVICE
European Statement
Clinical Pharmacy Services
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.
IMPROVING THE CONTINUITY OF CARE IN CASE OF EXTRATEMPORANEOUS MEDICINES FOR CHILDREN
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Stefanie Sauer, Michael Ober, Jürgen Backhaus, Torsten Hoppe-Tichy
Why was it done?
Patients of the Children’s Hospital at the Heidelberg University Hospital are regularly supplied with extratemporaneous medicines from the hospital pharmacy. This often leads to issues in continuity of care in the outpatient setting as patients are required to access ongoing treatment through local pharmacies, which in turn must develop the formulations and procure the necessary raw materials. Therefore, it is not uncommon for interruptions in patients’ therapy to occur.
What was done?
The aim was to improve continuity of care by discussing the medication with the responsible pharmacy before the patient was discharged. Allowing missing raw materials to be procured and clarify any uncertainty about the prescription.
How was it done?
We designed a document that is available on the Intranet. While the child is still on the ward the discharge medication should be noted. The parents had the opportunity to indicate a retail pharmacy of their choice, preferably near the place of residence. This document could be sent to the hospital pharmacy. A hospital pharmacist contacted the specified pharmacy to discuss the extemporaneous medications before the child was discharged. If necessary, the pharmacist can forward the hospital pharmacy manufacturing instructions. Furthermore, the compositions plus further information were then made available on the homepage of the pharmacy in an area to which only experts have access. A telephone number on the hospital pharmacy homepage is available for queries, including those about the formulations.
What has been achieved?
In the discussions with the retail pharmacies, the colleagues were very pleased and grateful about the service provided by the hospital pharmacy. They saved time in preparing patients’ prescriptions. Concerns or doubts were cleared up at an earlier stage of the discharge process, leading to the patient receiving their medicine on time.
What next?
Provision of the document and manufacturing instructions on the homepage serve as a valuable aid for ensuring that the outpatient therapy functions smoothly. It is important that the information is kept current. In the future, further information will be linked to the homepage in the hope of reducing the number of incoming telephone enquiries.
SAFER DRUGS WITH AWARD-WINNING DATABASE
European Statement
Patient Safety and Quality Assurance
Why was it done?
Hospitalised patients often need multiple IV drugs simultaneously which are commonly mixed in-line before entering the bloodstream. Physicochemically incompatible drugs cause reduced efficacy, clogged catheters and drug precipitation, which can be harmful or even fatal. The risks add uncertainty to the stressful working environment for clinical practitioners. According to a local 2012 survey 68% (n=44) of Sahlgrenska University Hospital (SUH) intensive care unit (ICU) nurses had co-administered drugs uncertain of their compatibility. Hospital pharmacists were hence asked for guidance to optimise compatibility and patient safety.
What was done?
Nurses, doctors and pharmacists were provided with accessible and evidence-based information on IV drug compatibility in order to improve drug therapy, working environment and patient safety.
How was it done?
Drug compatibility data was collected by hospital pharmacists who assessed its applicability to Swedish conditions. The results were documented in charts and procedure documents. A project for creating a database was initiated in collaboration with the IT organisation in Västra Götaland Region (VGR). A survey was designed to evaluate how the SUH’s ICU nurses experienced the database. Collaboration with nurses, doctors and clinical pharmacists helped to improve the quality of the database.
What has been achieved?
Drug compatibility lectures were given to nurses, doctors and pharmacists on a continuous basis. Procedure documents were implemented in eight clinics. A peer-reviewed workflow was established. The database contains over 2,500 assessed drug combinations. Over 700 nurses, doctors and pharmacists from 11 counties plus Norway and Denmark have requested access to the database. Clinics avoid drug mixing by choosing multi-lumen catheters with greater capacity. The 2016 survey showed that 88% (n=86) of SUH’s ICU nurses had co-administered drugs uncertain of their compatibility. The database affected their decisions in 93% (n=45) of the cases, 85% (n=34) found information easier and 88% (n=34) felt more certain when making decisions. A new pharmacist role – IV Compatibility Manager – was introduced and implemented in VGR. In 2016, this work received the national annual award Guldpillret (‘The Golden Pill’).
What next?
In the next years, the database will become nationally available and integrated into electronic journal systems. Compatibility issues may then be identified when prescribing, further improving patient safety.
IMPROVING PATIENT FLOW: NOVEL APPROACH TO COMPLETING DISCHARGE SUMMARIES BY PHARMACIST PRESCRIBERS
European Statement
Clinical Pharmacy Services
Author(s)
Louisa Kasprowicz, Elizabeth Wright, Tejal Vaghela, Mohan Thaoa
Why was it done?
The time taken from decision to discharge to discharge summary written on average was 2.5 hours prior to the new service as the clinicians completed the ward rounds before starting on completing the discharge summaries. Prior to implementation of this service the prescribing error rate was 24% and the accuracy of information (medicines started, discontinued and altered during admission) transferred to general practitioners (GPs) was 44%.
What was done?
The novel approach to completing full discharge summaries by independent pharmacist prescribers (PP) was implemented in a busy admissions unit at a large district general hospital in the east of England. PP writing discharge summaries are recommended in the ECIP, Carter and hospital transformation plans.1 2 We introduced the completion of a full discharge summary by PP instead of a medication-only list currently carried out by other NHS Trusts. The aim was to reduce prescribing errors, improve patient flow through AAU and to reduce pressure on the emergency department.
How was it done?
A pharmacist prescribing a discharge service from 9am to 3pm was proposed for patients who have been admitted for < 48 hours. The medical team bleeped the PP when a patient was being discharged to alert the PP. The primary aim of the service was to increase the number of discharge summaries completed before 3pm, reduce the prescribing error rate and to improve the accuracy of information transferred to GPs. The time of 3pm was chosen to allow the clinicians to complete urgent jobs after the ward round.
What has been achieved?
The data showed that after the implementation of the pharmacist prescribing service, 34% of discharge summaries were completed by PP compared to 0% prior to implementation. This released junior doctors time from completed discharge summaries to concentrate on urgent clinical duties. This also meant discharge summaries were received by the pharmacy in a timelier manner and patients were ready for discharge earlier in the day. The prescribing error rate was reduced to 0.9% and the accuracy of information to GPs was increased to 98% on discharges summaries completed by PP compared to junior doctors’ discharge.
What next?
This new service has made a positive impact on the discharge flow from AAU. Patients are receiving their discharge medications earlier so improving patient flow and patient experience through the department. The service has received positive feedback from patients, the lead consultant, doctors and nursing staff. It is hoped in the future this service could be extended until 5pm and rolled out to other areas in the hospital.
ACTIVE PARTICIPATION OF THE HOSPITAL PHARMACIST IN THE OPTIMIZATION OF ANTIMICROBIAL THERAPY AFTER OBTAINING THE MICROBIOLOGICAL RESULTS
European Statement
Clinical Pharmacy Services
Author(s)
Pilar Aznarte-Padial, Lourdes Gutierrez-Zuñiga, Carmen Valencia-Soto, Sara Guijarro-Herrera, Carmen Hidalgo-Tenorio, Juan Pasquau-Liaño
Why was it done?
Re-evaluation of empirical antimicrobial treatment, after knowledge of the microbiological results, is a practice that contributes to the proper use of antimicrobials, but the consultation of these findings by the medical prescribers may be delayed. The hospital pharmacist is an essential member of Antibiotic Stewardship programs, who can maintain an individualised monitoring of prescription and maintaining direct communication with the medical prescribers. The monitoring of the antimicrobial prescriptions and the revision of microbiological results, allows us to carry out an individualised advice to optimise the antimicrobial therapy
What was done?
Pharmaceutical advices were sent from the Pharmacy Service to the prescribing doctor, through the Electronic Prescription Program (EPP) to optimize antimicrobial therapy after the microbiological results are known
How was it done?
From January 2015, together with daily monitoring of prescriptions of antibiotics, the results of microbiological cultures requested were consulted. We started to send warning messages from the Pharmacy Department to doctors, through EPP. Our goal was to advise in relation with microorganisms resistant to the prescribed antibiotic, microorganisms not covered and proposals of the de-escalation.
What has been achieved?
During 2015, we made 166 communications; 20 the same day of the discharge. Of the remaining 146, 46 were of de-escalation, 44 of resistant antimicrobials and 56 of non-covered microorganisms. Global acceptance was 80.1% (117/146): 80.1% of the de-escalation, 81.8% of antibiotic resistant microorganisms and 78.6% of non-covered microorganisms. The Services which received more advices were: Internal Medicine (57/146), General Surgery (38/146) and Pneumology (9/146), with an acceptance of 82.5%, 76.3% and 100.0%, respectively. The carbapenems were the most involved antibiotic group (58.9%). Ertapenem was involved in advices of non-covered microorganisms in 21.4%. The most commonly used antibiotics after the de-escalation were: fluoroquinolones (18.9%), beta-lactams with a beta-lactamase inhibitor (10.8%), fosfomycin (10.8%) and ampicillin (10.8%).
What next?
The acceptance degree obtained permits to consider this initiative as a valid strategy to optimize antibiotic prescriptions. This procedure reduces the use of restricted antibiotics, by lowering the cost of treatments and the resistance emergence.
THE IMPACT OF A NOVEL CLINICAL DECISION SUPPORT SYSTEM ON ANTIMICROBIAL STEWARDSHIP AT AN ACUTE NHS TEACHING HOSPITAL
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Stephen Hughes, Katie Heard
Why was it done?
The context, strategies, and delivery of AMS vary markedly between hospitals, largely falling within two headings, that of restriction or enablement. Restricted access to broad-spectrum antimicrobials through pharmacy and microbiology control of supply is the most common approach as requires minimal resource and implementation. This controls antimicrobial misuse but the long term benefits are less clear. The negative professional culture this restriction develops may erode inter-professional trust and delay time to first-dose, negatively impacting upon sepsis management whilst approval is sought. CDSS was used to transform the working role of the AMS team.
What was done?
A real-time clinical decision support system (CDSS) has been tested and implemented for the first time in an acute NHS hospital. CDSS has enabled the service evolve from an effective restricted antimicrobial stewardship (AMS) service to a more desirable enablement service, where the team aspires to support all prescribers to take responsibility for good AMS practice
How was it done?
In April 2016 a commercial CDSS was introduced at a single site London teaching hospital with an established, multi-professional AMS team. A service evaluation was conducted to understand the impact of CDSS on practice. Data was collected for three months pre and post implementation, including time spent compiling data for AMS daily ward round, the number and types of ABX-related interventions made and total antimicrobial use (defined daily dose [DDD] per 100 occupied bed days [OBDs]).
What has been achieved?
Implementation of CDSS saw a transformation of the AMS service from tele-consult service from the microbiology labs to a patient-facing ward based service, through use of mobile technology. The relocation of AMS team staff resource allowed for increase ward presence and daily ward rounds on surgical, medical and admission wards. AMS interventions increased (138/quarter to 298/quarter) post-intervention. Clinician acceptance of AMS team interventions increased from 81% to 98%. High-impact interventions, such as escalation of septic patients, early discharge and ID reviews, increased on the ward based reviews. Total ABX (DDD/100OBD) reduced by 18% over study period.
What next?
The CDSS is being used to evolve the service to further support AMS practice. Patient orientated outcome data is being collected and used to drive further service improvements
ANTIMICROBIAL STEWARDSHIP ALERTS SYSTEM
European Statement
Patient Safety and Quality Assurance
Author(s)
Emma Ramos Santana, Enrique Tevar Alfonso, Maria Jose Castillos Mendez, Maria Luz Padilla Salazar, Lucy Abella Vazquez, Jesus Ode Febles, Marcelino Hayek Peraza, Javier Merino Alonso
Why was it done?
The implementation of an antimicrobial stewardship program (AMS) is very important, but it has to be accompanied by personal resources. It is therefore necessary to effectively use the time spent in the AMS.
What was done?
We have worked with the Information Technology Service to develop an “Intelligent Antimicrobial Screening Program” (IASP).
How was it done?
Using the information available in Electronic Health Record (EHR) and in pharmacy and microbiology applications we have developed a computer tool that analyze hundreds of situations through pre-established conditions
What has been achieved?
Currently the system analyzes more than 40 conditions related to the correct use of antimicrobials based on antibiotic characteristics, patient situation and microbiological data.
Some of the most relevant conditions are:
●Antibiotic prescribed more than 6 days.
●Patient with parenteral antibiotic for more than 3 days and with other oral medicines.
●Antibiotic that must be adjusted in patients with renal impairment prescribed in patients with glomerular filtration rate (GFR)65 years old, GFR5 days prescribed or other nephrotoxic prescribed.
●Patients with linezolid and thrombocytopenia or anemia or without an hemogram in the last week.
●Patients with daptomicyn and high creatininkinase (CK) or without a recent determination.
What next?
This software allows to collect information contained in different systems and displays it in an organized view to the user. This makes it an easily system that can be exported to other hospitals.
Our next objective is to consult the microbiological information. Therefore the system will be able to recommend about the optimal antimicrobial treatment, detecting situations in which the treatment can be de-escalated or alerting in case of resistance.
OPIOID ROTATION IN PEDIATRICS: A CONVERSION CHART FOR CHILDREN OLDER THAN 1 YEAR
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Sabina Hiltbrunner, Dalibor Panis, Jörg Thomas, Eva Bergsträsser, Angela Caduff Good
Why was it done?
Opioids are widely used for acute pain management in pediatrics after surgery, for sedation on the intensive care unit, and chronic pain management in palliative care and many other conditions. In some patients, it is necessary to change the opioid during therapy, due to tolerance development or due to side effects. Although conversion tables for adults are well established, they are not readily available for pediatric use.
What was done?
To simplify the process of opioid rotation in pediatrics, an opioid conversion chart with easily memorable conversion factors was generated.
How was it done?
A literature search was performed to collect conversion factors and equivalent doses of opioids with different application routes. We searched specifically for conversion factors in pediatrics. Except for Oxycodone and Remifentanil, for all other opioids in our chart conversion factors for pediatric patients were found. Data for adults were used for these two substances. For all conversion factors experts confirmed their adequacy for clinical use in pediatrics. The conversion factors were rounded up to whole numbers, which was considered reasonably based on long-term experience in pediatric pain manage-ment.
What has been achieved?
This conversion chart is now part of a drug information document about opioid dosing in children older than 1 year in our hospital. For every substance, starting doses were set according to www.pediatric-dosages.ch and based on clinical experience. When necessary, details about the therapy with the indi-vidual substance were added. For illustration purposes, a sample calculation of the change from oral Morphine to oral Oxycodone was included.
The immature metabolism in children younger than 1 year makes the opioid action often unpredictable. Therefore we restrict the use of the chart for children older than 1 year and in younger children specialists in pain management should be consulted.
What next?
Our opioid conversion chart, with easily memorable conversion factors and starting doses, supports all healthcare professionals in pediatric pain management and may also help to reduce critical incidences due to mistakes in calculation. This is the first time an opioid conversion chart is established for pediatric purpose. Its impact on patient safety has to be shown in the future.
IMPLEMENTATION OF GUIDELINES FOR THE ACTIVATION OF EFFECTIVE ANTIBIOTICS’ STEWARDSHIP TEAM IN GREEK HOSPITALS – THE ROLE OF HOSPITAL PHARMACIST
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Antonios Markogiannakis, Georgios Pegkas, Calliope Allagianni, Stavroula Efstathiou, Despoina Makridaki
Why was it done?
The term of AST has been introduced in Greek legislation since 2014 and should become the driving force to optimize antimicrobial therapy, especially for the protected antibiotics (PA): carbapenems, colistin and tigecycline. Unfortunately Greece ranks first in Europe in the consumption of the mentioned PA in hospitals, consequently the activation of AST constitutes national priority. The existing law frame defines that AST consists of four key member physicians (experienced in infectious diseases) plus the hospital pharmacist as coordinator of the group. As the number of serving pharmacists in Greece remains critically low, very few hospitals have actually activated the AST. The Panhellenic Association of Hospital Pharmacists (PEFNI) decided to organize regional meetings to enhance the involvement of pharmacists by sharing the practice of experienced colleagues running antibiotic stewardship programs (ASP) in their hospitals since fall of 2016.
What was done?
We have described the sequential steps for the establishment of multidisciplinary Antibiotic Stewardship Team (AST) in Greek hospitals and prepared training material to increase involvement of hospital pharmacists.
How was it done?
We combined the strategies and procedures implemented in the three hospitals during last year, in a flowchart presenting the establishment, activation and feedback of the AST. We have developed an ASP for hospitals, with initial target to minimize the use of PA:. Functional options in each step have been described, making it flexible for the colleagues to selectively implement them in their hospitals. We also created specific educational material to use in regional meetings that PEFNI organizes.
What has been achieved?
The application of ASP and the education of hospital pharmacists as coordinators results in: • Reliable reporting of controlled use for the PA • Safer antimicrobial management practice • Economy on restricted pharmacotherapy budgets • Acknowledgement of the critical role of pharmacists by other healthcare professionals, the hospital manager and the authorities
What next?
• The basic flowchart can be broadened to include subsequent stewardship activities such as recording proper surveillance of more classes of antibiotics, assessment of antimicrobial surgical chemoprophylaxis and/or antifungal pharmacotherapy.
• Connection of local ASP reports to a national network for all hospitals will help towards the creation of a real-time antibiotics’ consumption database in Greece.