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Author(s)

Andrés Sánchez Ruiz, Rocío Contreras Collado, Lucía Gutiérrez Lucena, Juan Jerez Rojas

Why was it done?

The programme began to be developed in March 2020 as an emergency solution to the COVID-19 pandemic, but over time it was refined due to the benefits seen in different areas, especially for pharmacy patients.

What was done?

A hospital drug dispensing programme was created with the collaboration of a community pharmacy and its pharmaceutical distributor. A daily delivery was conducted from the hospital pharmacy, covering the entire province, with a population area of 622,000 inhabitants and an area of 13,500 km2 that includes widely dispersed population centres with complicated communication.

How was it done?

Interlevel collaboration between hospital pharmacy, official college of pharmacists, pharmaceutical distributor and community pharmacy. After the first year, in which the process was more manual and marked by the pace of the pandemic, the programme began to develop. A web application with two-way communication hospital-community pharmacy was created. Hospital Pharmacy reviews and dispenses these requests, with daily shipments to all community pharmacies in the province through the distributor, which ensures safe transportation of the medication with adequate conditions of humidity and temperature.

What has been achieved?

A total of 57,130 dispensations have been made since 2020 (8,089 in 2020, 14,996 in 2021, 16,629 in 2022 and 17,416 in the first half of 2023). Pharmacy Service has dispensed at least once to 5,091 patients. Thanks to the reduction of individual trips (a total of 3,529,022 kms, 52,669 hours travel time, since 2020), it is estimated that the discharge into the atmosphere of 500 tonnes of CO2 in total has been avoided, which is equivalent to the emission of 500 round-trip Spain to Denmark flights (1,000 medium-sized trees are needed for 50 years to absorb that amount of CO2). Eighty-seven percent of private car use was estimated. We did not take into account movements of patients residing in the urban centre of the hospital. The development of ICTs will allow a more clinical approach and an improvement in patient care. We also expect the improvement of the process with the creation of Patient Reported Outcomes (PROs) protocols, already underway for migraine and psoriasis, and Patient Reported Experience Measures (PREMs) protocols.

What next?

The development of ICTs will allow a more clinical approach and an improvement in patient care. We also expect the improvement of the process with the creation of Patient Reportes Outcomes (PROs) protocols, already underway for migraine and psoriasis, and Patient Reported Experience Measures (PREMs) protocols.

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Author(s)

Suzanne Al-Rawi, Sadeer Fhadil, Sotiris Antoniou, Rodnie Oro, Paul Wright

Why was it done?

It is suggested that 40-80% of information provided by healthcare professionals is forgotten immediately by patients (1). The trust has a checklist of counselling requirements for anticoagulants, completed in consultations with patients before discharge. Recognising the complexity of anticoagulation counselling and its time constraints, we sought to assess the use of pre-recorded counselling videos for use at ward level and as a resource for patients to refer to post discharge.

What was done?

We sought to develop anticoagulation counselling videos for ward use, with hyperlinks for patient access post-discharge. We aimed to improve information provided to patients and optimise pharmacists’ time undertaking counselling.

How was it done?

Using a patient focused questionnaire, feedback was sought on patient satisfaction as well as time totality following anticoagulation counselling. A series of short and digestible video clips (1-2minutes each) that reflected the trust checklist were recorded. The videos were played to the patient and then a follow-up face-to-face consultation was undertaken to answer any questions. Patient satisfaction and time taken was assessed through the use of the questionnaires and compared to consultations without the pre-recorded clips.

What has been achieved?

Over 4 weeks, 121 patients received anticoagulation counselling. 77 patients were counselled using videos and compared to 45 patients counselled without videos. There was a 70% reduction in time spent; an average face-to-face counselling required 24 minutes, compared to only 7 minutes if the patient had seen the videos. There was an overall increase in patient satisfaction with use of videos to 86% from 70%.

What next?

We have shown optimisation of the anticoagulation counselling process through the use of pre-recorded videos. Time spent counselling has been significantly reduced and feedback from pharmacy staff has suggested more patient-centric counselling is achieved. It has allowed for information to be standardised, with an increase in patient satisfaction and understanding. Patients have access to the videos on discharge to improve patient safety. There have not been any reported incidences since switching methods. There has been a reduction in patient queries related to anticoagulation post- discharge. Areas for further development include dubbing of the videos to several languages to improve access to all.

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)

MV VILLACAÑAS PALOMARES, CM VALENCIA SOTO, A GARCIA-AVELLO FERNANDEZ-CUETO, M MARTIN LOPEZ, S BARBADILLO VILLANUEVA, M OCHAGAVIA SUFRATEGUI, V MARTINEZ CALLEJO, M RIOJA CARRERA, P DEL RIO ORTEGA, M VALERO DOMINGUEZ

Why was it done?

This drug is administered continuously during a 28 days infusion. Due to the risk of cytokine release syndrome (CRS) it is initially administered in the inpatient setting and then transitioned to the outpatient, requiring an important interdisciplinary coordination to optimize the process.
Home-based chemotherapy offers several potential benefits: reduced exposure to hospital infections, less disruption of routine and family life, lower health care cost, …

What was done?

Pharmacy and haematology services designed a workflow for the outpatient administration of blinatumomab, a bispecific T-cell engager approved for relapsed ALL.
Here, we describe our experience transitioning from inpatient to outpatient setting.

How was it done?

First step was to review blinatumomab stability, as well as material compatibility and transfer set necessaries for both hospital and domiciliary administration.
Reconstituted blinatumomab may be stored at refrigerated (2-8°C) for up to 24 hours. Prepared infusion bag (with preservative) may be stored at room temperature (up to 27°C) for up to 96 h and for up to 10 days refrigerated (2-8ºC).
Second step was to establish with the haematology service the patient´s scheduled visits to the hospital to ensure maximum stability of the blinatumomab preparation.
We decided to prepare the blinatumomab infusion bag every three- or four-days beginning on Monday, Thursday or Friday avoiding visits on weekends.
In order to take advantage of the rest of the vial, we diluted itn a new bag with stabilizer solution but without in-line filter for the next preparation. We noted the date of elaboration and the amount of medication remaining.
We used this preparation initial in each new visit add the dose necessary and an in-line filter. We primed the filter with the prepared solution for infusion

What has been achieved?

Out of the four patients who have received blinatumomab in our hospital(May 2020 – September 2021), three have benefited from this circuit.18 doses were administered at home, avoiding 68 days of hospital admission.

What next?

Outpatient administration could reduce health expenditure, therefore allowing for additional investments in new therapies.
Since the use of blinatumomab is not very common and there is not much evidence at this respect, our experience can help other Pharmacy Services to implement this circuit.

Why was it done?

Due to the increased risk of infection to asplenic patients by encapsulated bacteria, national guidance states the following vaccinations should be administered at least two weeks prior to elective splenectomy: influenza, meningococcal (meningitis B and meningitis ACWY), Neisseria meningitides group B, and pneumococcal. Anecdotally this does not happen, resulting in administration in the hospital setting. This adds complication to the discharge process and leaves the patient with follow-up to arrange at home, whilst also having a cost burden to the hospital.

What was done?

An audit was carried out to assess compliance with national guidance on administration of vaccinations in primary care prior to elective splenectomy.

How was it done?

A report was run to generate a list of all patients who underwent a splenectomy over a 5-year period between 2015 and 2020. The records of patients admitted for elective splenectomy were investigated. It was ascertained whether medication and vaccination histories had been completed by pharmacy, whether vaccinations were given whilst in the secondary care setting, and whether the appropriate follow-up information was given to the general practitioner (GP) on discharge.

What has been achieved?

Only 6% of patients admitted for elective splenectomies across the 5-year period had received the required vaccinations in primary care prior to admission. If not administered by their GP prior to admission, only 69% of patients received the required vaccinations following splenectomy before discharge from hospital. Inclusion of the required information regarding long-term management in the discharge notification was completed in 76% of cases. Often this was included by the screening pharmacist in the pharmacy section of the discharge summary, where this was omitted by the discharging doctor. These results were submitted to the quality improvement team with recommendations to improve future practice.

What next?

This audit highlighted the need for a substantial improvement in communication between hospital and GP settings, utilising the new electronic era. In the hospital setting, poster reminders and regular teaching sessions for new and regular staff on the importance of these vaccinations will be implemented. Re-audit should then take place, with an additional component looking at communication processes and implementation by GPs of suggestions made on discharge.

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Author(s)

Ana Pelaez Bejarano, Maria de las Aguas Robustillo Cortes, Pilar Villar Santos, Olalla Montero Pérez, Ignacio Garcia Gimenez

Why was it done?

Rheumatologic disorders carry increased risk of infection compared with the general population, so facilitate access to hospital medications is of vital importance.

What was done?

On 14 March 2020, the Spanish government declared a state of alarm to deal with the spread of COVID-19. Medication dispensing protocols were immediately established to deliver drugs to patients who could not come in person to the hospital pharmacy department. These measures were designed to benefit citizens who, due to age or physical fragility, were more vulnerable to contagion. We had the collaboration of community pharmacies actively practicing during the COVID-19 pandemic and a logistics service, with no extra cost to the public healthcare system.

How was it done?

Between 30 March and 1 September 2020, a circuit was designed as follows: First, patient request the delivery service in the community pharmacy of their choice, which sending the request of each patient to college of pharmacists. Later, this institution sending of applications received from all pharmacies to hospital pharmacy. Here, the hospital pharmacist reviewed the patient’s electronic medical record, checking that the medication requested was appropriate, modifying it if deemed necessary (change of drug, dose, and so on). A pharmaceutical cooperative sending antirheumatic drugs to the community pharmacies. Finally, the community pharmacist who received the package checked the medication and, with the patient, reviewed and reinforced the information on the treatment.

What has been achieved?

587 patients were included: 211 rheumatoid arthritis, 173 psoriatic arthritis, 121 psoriasis and 82 ankylosing spondylitis. The delivery service enabled us to provide antirheumatic drugs to patients in their immediate environment through a service that was free for both the patient and the hospital pharmacy service. This contributes to guaranteeing the achievement of the pharmacotherapeutic objectives established for these patients.

What next?

Further action is needed to identify which groups of patients require more intensive pharmaceutical care and, therefore, who could benefit most from telepharmacy, and not only the delivery service.

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Author(s)

Tania Truelshoej

Why was it done?

Department of infectious diseases at Aarhus Universitetshospital, Denmark, has succesfully implemented OPAT as a standard modality for certain patients requiring long-term intravenous antibiotic therapy e.g. patients with cystic fibrosis. This also include a guideline to OPAT self-administration at home.

To implement the OPAT guidelines throughout the hospital there was a need for an overview of available ready-to-use antibiotics for OPAT. The graphic guide is a help for the physicians in choosing the right drug-delivery-system suitable for OPAT self-administration.

What was done?

A graphic guide showing the ready-to-use antibiotics for outpatient parenteral antimicrobial therapy (OPAT) with special emphasis on drug-delivery-systems suitable for self-administration was developed.

How was it done?

Most information about the available ready-to-use antibiotics were obtained at the hospital pharmacy. In addition, the requirements for the different drug-delivery-system were obtained by interviewing nurses from different wards

What has been achieved?

Available ready-to-use antibiotics was listed in a graphic form with the following information: type of antibiotics, drug-delivery-system, available doses recommendations to time of administration and storage time and temperature. The drug-delivery-system were all illustrated with a photo.

The graphic guide is now part of the implemented guideline for OPAT at the hospital and is also available as a printed poster to place e.g. in the medicine room.
The guide is a help for the physicians in choosing the right drug-delivery-system suitable for OPAT self-administration and helps to raise overall awareness of the possibility of OPAT as self-administration at the hospital.

What next?

Implementation of the OPAT guideline and the included graphic guide has increased awareness of the need for the hospital pharmacy to deliver ready-to-use antibiotics that can match the needs for safe and efficient treatment at home. This is an important strategic focus for the hospital pharmacy in the coming years.

Author(s)

Marianna Rivasi, Gregorio Medici, Lucia Ricchi

Why was it done?

Because of the need to administer DA-EPOCH over a continuous 96-hour period, patients are traditionally hospitalized. Frequently, these admissions may be delayed because of bed shortages. Previous studies have shown that EPOCH-containing regimens can be safely administered in the outpatient setting, thus decreasing inpatient bed use and overall health care costs. Home-based chemotherapy is normally preferred by patients and helps reduce the risk of hospital-acquired infections; furthermore, other aspects such as functional decline and social isolation are minimized. Beginning in August 2019, we introduced an outpatient EPOCH-based chemotherapy model with portable infusion pumps and have already treated 9 patients.

What was done?

DA-EPOCH (etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin) -based chemotherapy is traditionally administered inpatient because of its complex protocol and number of involved medications. These routine admissions are costly, disruptive and isolating to patients. Here we describe our experience transitioning from inpatient to outpatient setting.

How was it done?

We purchased 3 CADD-SOLIS infusion pumps (Smiths Medical) and connected them to the bags containing chemotherapy. One of the main issues we observed in this procedure was the flow disturbances due to the presence of small air bubbles in the pump delivery line so we tried to develop a method aiming to reduce this effect.
We changed the first type of device we used with a new one consisting of an irreversible spike needle-free access to IV bag (BTC, Italia) inserted to the medication port of the bag. Into the spiking port we insert the CADD High-Volume administration set. It is crucial to remove all the air inside the IV bag and make sure there is no extra air injected into the bag when adding medication, finally do not forget to fully prime the tubing.

What has been achieved?

Outpatient EPOCH administration was associated with cost savings of approximately 400.000€ for both chemotherapy costs and hospital day avoidance (45 days). In addition to cost savings, outpatient administration improve patient satisfaction, without any apparent decrement in treatment efficacy.

What next?

Outpatient treatments would lead to changes in how both patients and providers relate to cancer care. Transitioning care out of the hospital and related cost reduction allowed for additional investments in public health.

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Author(s)

Michael Scott, Glenda Fleming, Catherine Harrison

Why was it done?

There is a wide recognition that there are significant issues with regard to the issue of medicines, such as the fact that 30−50% of medicines are not taken as required. Thus the DoH decided to set up MOIC as a vehicle to focus activities in order to address this issue and optimise medicines use.

What was done?

A Regional Medicines Optimisation Innovation Centre (MOIC) was set up in 2015 by the Department of Health (DoH) in Northern Ireland as a key enabler for the Government policy document namely the Medicines Optimisation Quality Framework.

How was it done?

The DoH requested the Northern Health and Social Care Trust to locate the centre within the Trust based on the fact that there had been a long standing academic practice centre with the School of Pharmacy at Queens University of Belfast. Barriers that had to be addressed were highlighting the regional nature of the centre, to get engagement with all sectors of the service and building relationships with other key organisations, including the private sector. Initial core funding was provided by the DoH.

What has been achieved?

MOIC has successfully evaluated improved systems with regard to hospital pharmacy such as doctor-light discharge (90 minutes faster), post-discharge telephone follow-up (30 day readmission rate reduced by 9.9%), and medicines optimisation in older people service in care home settings (reduced Emergency Department attendances and medicines costs). In addition MOIC has been successful in 3 EU funding bids relating to medicines optimisation and has published over 30 papers. It has also been accredited as a Statement Implementation Learning Collaborative Centre (SILCC) site and also a Centre of Excellence by the Spanish Hospital Pharmacists Association. MOIC has also successfully worked with the private sector including pharmaceutical, device and technology companies. It has also been accredited as a knowledge provided by Invest NI.

What next?

MOIC has delivered on its key initial objectives, related to medicines optimisation with good collaborative work across health, academia and commercial organisations, in the UK and Europe. It will have a key role in meeting the WHO Global Challenge of reducing medication-related harm by 50% by 2023 for the region and further optimising medicines systems.

This approach with government policy support could be relatively easily established in any other region.

Author(s)

Guillaume Wabont, Jean-Philippe Hammelin, Guénaëlle Faure, Cathy Debruille, Kévin Raynaud, Pascale Guillain

Why was it done?

Clinical pharmacists and nephrologists noticed a recurrence of rehospitalization of patients who recently underwent ileostomy because of prerenal acute kidney injury. Ileostomy tends to enhance dehydration, but in each case there was a drug that was exacerbating the phenomenon by inhibiting the RAAS. The digestive and urologic surgeons had no knowledge of such pathophysiology and iatrogenia, explaining why they continued to prescribe such drugs.

What was done?

We elaborated an internal guideline for the treatment of high blood pressure (HBP) in patients with ileostomy. We decided to contraindicate to those patients the inhibitors of renin-angiotensin-aldosterone system (RAAS) such as angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs) or direct renin inhibitors (DRI); as well as the diuretics – even-though none of the summaries of the product characteristics (SmPC) of those drugs in question require such prohibition.
From now on, the drug(s) of the first line of treatment must be a beta-blocker and/or a calcic inhibitor. The drug(s) of the second line of treatment must be an alpha-blocker and/or an imidazoline-receptor agonist.

How was it done?

Therefore, we decided to set up a collective analysis of the situation with pharmacists, nephrologists and surgeons in digestive and urologic surgery, to understand the pathophysiology and to elaborate an internal guideline for HBP in patients with ileostomy.

The pharmacists first wrote a working paper retailing:
– the pathophysiology (water–electrolyte imbalance with ileostomy and deterioration under RAAS inhibitors or diuretic)
– the lack of information in the SmPC of the drugs in question
– an argued suggestion to contraindicate those drugs
– the therapeutic alternatives

Then we all met and exchanged views on the subject.

What has been achieved?

The guideline has been written in a collaborative and multi-disciplinary work. It applies to all the physicians and pharmacists of the hospital who have been informed of our approach and they have received a copy of it.

What next?

We will evaluate the respect of the guideline in our hospital as well as its impact in the lowering of the rehospitalization rate of patients who recently underwent ileostomy.
We will notify our national agency for medicines of our procedure because we think it should be a national standard.