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Author(s)

MARTA VALERA-RUBIO, ROSARIO MORA-SANTIAGO, MARIA ISABEL SIERRA-TORRES, JOSE LUIS ORTIZ-LATORRE, ISABEL MOYA-CARMONA

Why was it done?

The existence of different prescription systems could lead to validation errors when the pharmacist responsible for the ICU is not available. Furthermore, ICU physicians could not benefit from all the advantages that the official prescription system included. The presence of a common integrated prescription system among all units allow the exchange of prescription drug information between the ICU and the rest of the units, in accord with the health situation of the patient. Moreover, with this new system they can have access to allergies, renal adjustment doses, recommended posologies, therapeutic exchanges, and pharmacy validation, among other items.

Moreover, with this new system they can have access to allergies, renal adjustment doses, recommended posologies, therapeutic exchanges, and pharmacy validation, among other items.

What was done?

The intensive care unit (ICU) used a computerised physician order entry system different from all the hospital units. The pharmacy service, along with the ICU physicians and nurses, have tried to adapt the special features of this unit to integrate it with the clinical decision prescription system that is official in the hospital.

How was it done?

A multidisciplinary team formed by ICU staff (doctors and nurses) and pharmacists met to discuss the points that should be followed when implementing the new electronic prescription programme. In these working meetings, especially with physicians, we tried to agree on what and how the infusion protocols would be included in the new system, based on the infusion pumps guides made by both units. A pilot phase was established by the end of July 2019 to detect possible errors in the process of prescription, and mostly, when a patient changed from two units, from the ICU to another health care service and vice versa. All errors or discordances found were discussed between the pharmacist and the physician or the nurse, and in order to solve them we contacted the managers of the prescription system or we modified the parameters that are included in the system such as names of drugs, dosage guidelines, new nurses’ orders, etc.

What has been achieved?

The implementation of this new system has been well embraced by the staff, since it allowed a more efficient and secure health care circuit for the patients. All physicians are now able to use this system while the other one is no longer used.

What next?

We will continue making formative sessions with both physicians and nurses, in order to solve all the doubts that can appear during the training period. We will update periodically the available data and make improvements in the programme configuration.

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Author(s)

MARTA VALERA-RUBIO, MARIA ISABEL SIERRA-TORRES, ELENA SÁNCHEZ-YAÑEZ, JOSE LUIS ORTIZ-LATORRE, ISABEL MOYA-CARMONA

Why was it done?

Critically ill patients often require the administration of several intravenous drugs and that includes infusion pumps. New infusion pumps offer the ability to build a drug library within the infusion system itself. This allows intravenous infusion medication safety to be improved. Because of that, it is highly important to have an updated administration guide and an IV smarts pumps library for the everyday clinical practice. This guide was developed in order to help ICU staff to practice safe prescribing and managing of medicines and to reduce the incidence of adverse drug events and administration errors.

What was done?

We developed an updated guide on intravenous drug administration including infusion parameters for intelligent intravenous infusion pumps, so called “IV smarts pumps”, used in the intensive care unit (ICU).

How was it done?

A database with the most important intravenous drugs used was created by a multidisciplinary working team (pharmacists, physicians and nurses). The drugs included were divided into therapeutic groups and were distributed among the participating members for the drug information review process. The therapeutics groups included were: sedatives, analgesics, antihypertensives, vasopressors, anti-arrhythmics and others such as insulin, heparin, etc. For each drug, a bibliographic research was conducted, gathering information from manufacturers, intravenous drugs databases (Uptodate®, Micromedex®, Stabilis®) and other hospital guidelines. The data collected included: drug name, lower and upper hard limit, default dilution, flow rate, default rate, rate upper soft and hard limit, bolus default, flow rate and volume upper limit, loading dose, duration, dilution volume, default, and lower and upper hard limit.

What has been achieved?

This guideline promotes, mainly, the safe use of drugs usually administered in critically ill patients, and is available for all the staff in this unit. Its elaboration has made it possible to avoid medication errors and to establish a narrower bound between the pharmacy service and the critical care unit, developing new partnerships which could lead to new projects.

What next?

We are still working on improving this guide, making it easier to understand and with a unified vocabulary. We will update it periodically in order to include new evidence and new drugs if necessary.

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Author(s)

Faten Ahmad Díaz, Eugenia Serramontmany Morante, Carla Esteban Sánchez, Pablo Latorre García, Montserrat Carreres-Prieto, Javier Martínez Casanova

Why was it done?

Different critical points were detected: 1) some OV dose prescription depends on tumor size, 2) special storage conditions, 3) special safety measures related to preparation to prevent cross-contamination and technician exposure, 4) special transport conditions in a safety container, and 5) safe administration. The increasing number of clinical trials with OV combined with the identified critical points implies a better coordination between the different departments involved.

What was done?

Development of a standardised working procedure for the safe handling considerations, storage requirements, and modes of administration of oncolytic viruses (OV) in patients with cancer.

How was it done?

Different meetings were arranged with a multidisciplinary team to standardise procedures, in order to avoid errors: 1. The pharmacist validates the prescription volume reflected on the certified sheet according to the tumour size. Then, a pharmacy technician is authorised to remove the vials from the freezer to start the preparation. 2. Special −80ºC freezer is needed to preserve the OV. 3. According to the preventive medicine service, OV must be prepared in biological safety cabinet class II (BSC) with personal protective equipment. At the end of preparation, the BSC must be cleaned with the OV appropriate disinfectant and ventilated for 1 hour before restarting to work again. So, the OV preparation was established at 7 a.m. in order to avoid cross-contamination with the chemotherapy (first preparation in the day). 4. Safety transport must be considered, so OV is packaged in a special hermetic box. 5. The majority of the OV preparations are administered intralesionally at the radiology room so safe administration is needed to avoid the room contamination.

What has been achieved?

By using these procedures, it is possible to work with a single BSC, avoiding delays in the administration of other therapies while reducing the risk of mistakes.

What next?

These types of therapies represent a novel therapeutic modality: their preparation, administration and handling requirements differ from current therapies; pharmacists have an important role in developing new procedures to incorporate them into clinical practice. This protocol may be useful to other centres due to the lack of experience and standardised guidelines to work with this type of therapy.

Author(s)

Mia P von Hallas, Trine RH Andersen

Why was it done?

Physicians in acute wards have limited time to see all patients. Time for medication history, reconciliation and review is limited, due to great patient turnover. The physicians did not consider the pharmacist medication review alone as a contribution to the workflow or to relieve the high workload.

What was done?

Through user surveys among the physicians in the Acute Ward, pharmacist tasks were adjusted to benefit the physician’s high work flow. Before the survey, pharmacists performed medication reviews which were communicated to the physician. The adjusted pharmacist tasks on the ward includes medication history, reconciliation and transfer of the medication to the electronic medicine module (Epic), securing up-to-date medicine data during hospitalisation.

How was it done?

A questionnaire was developed regarding four areas (Pharmacist competencies, Pharmacist tasks, Pharmacist medication review, Multidisciplinary teamwork) and distributed among the physicians. Based on the anonymous responses, the pharmacists adjusted their tasks to include medication history, medication reconciliation and transfer of medication to Epic, complying with the suggestions in the questionnaire survey. Obstacles were low percentage of respondents (15/33 (45%) prior to the initiative and 12/39 (31 %) after), and the large replacement of junior physicians in the period between surveys.

What has been achieved?

Pharmacists feel more part of the multidisciplinary team and attitudes towards the pharmacist service among physicians has changed. A new survey after implementation of the new workflow showed that 73% found medication reconciliation was a pharmacist task, compared to 29% before. After implementation, 90% of physicians believed that pharmacists could do medication review (67% before intervention). The acknowledgement that pharmacists were able to transfer medication to Epic was increased from 20% to 90%. The attitude has changed from considering pharmacists as medication advisers to considering pharmacists as part of the multidisciplinary team in the ward.

What next?

The questionnaire survey will be repeated annually to continually improve the workflow and contribution of clinical pharmacist services to the heathcare professional team in the acute ward.

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Author(s)

SALIM HADAD

Why was it done?

It remains that new solutions to increasing the safety of handling Solid Dosage Form hazardous drugs have to be developed. Conceptually, through operating in a closed system, CSTDs should significantly reduce the risks to pharmacists and nurses There are two main drawbacks of the known solutions:
1. The crushing and dilution of the solid dosage form medicine is done with an open vessel to the environment, such as a porcelain crater, which may cause the work environment to be contaminated with carcinogenic or teratogenic substances, that could expose and endanger the medical staff to hazardous substances in the course of their duties as providers of medical care.
2. The tools available today are reusable, requiring a thorough cleaning process between different materials (drugs), which can lead to cross-contamination between different doses of drugs, which are crushed one after the other with the same instrument.

What was done?

CSTD – for oral dosage form new device of its kind, combines the act of crushing the various drugs, dissolve in liquid and give to a patient who cannot swallow for various reasons, that mechanically prohibits the transfer of environmental contaminants into the system and the escape of hazardous drug or vapor concentrations outside the system.

How was it done?

We designed the device with 3D software (solid wark). It consists of a number of functional parts. The main ones are: a 20 ml barrel, a top part of which is a piston with a bottom basket loaded with the solid medicine; this part is sealed as a barrel from above. With the help of mechanical rotation, the drug breaks down into small particles that fall into the inner space of the barrel. Adding the liquid through a fluid port disposed on the bottom barrel which it is completely sealed. The removal of the liquid drug through a unique adapter which at its end is adapted to the gastric tube or oral administration to the patient,

What has been achieved?

1. The complete process of crushing and liquefying of the solid drugs is carried out under sealed conditions to the immediate environment and without fear of exposure to residues of toxic substances to the medical caregiver. 2. A one-time use system saves complex cleaning process. 3. There is no risk of cross-contamination between different drugs. 4. Saving personal protective equipment such as gloves, masks, lab coats clean rooms, etc. which is necessary for protection and for the safety of the caregiver team.

What next?

Applied research will be carried out by pharmacists and nurses to test the efficiency of the new device (as a basic prototype). These experiments will take various non-cytotoxic pills, will be dummy operations, in which the crushing and liquefying will be performed, and the solution or suspension will be transferred through the gastric tube, according to an approved research protocol.

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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.

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Author(s)

MARGHERITA GALASSI, CHIARA DELLA COSTANZA , CLAUDIA TIRONE, SARA BERTOLI, ERNESTO RUFFINO, ELEONORA FERRARI, ELENA ALIPRANDI , VITO LADISA

Why was it done?

CAR-T cell therapies are a new advanced type of personalised immunotherapy against cancer. In the EU the authorised therapies are tisagenlecleucel and axicabtagene ciloleucel, both used in our centre as third line for the registered indication of diffuse large B-cell lymphoma. CAR-T therapies production and administration process consists of multiple stages: patient’s leukapheresis, genetic engineering of lymphocytes, lymphodepleting chemotherapy (LC), CAR-T cell infusion, monitoring of the patient. Considering the complexity of the procedure and the observance of specific schedules, these therapies should be administered in highly specialised centres complying with specific organisational requirements, with disposal of an adequate multidisciplinary team.

What was done?

A multidisciplinary team (CAR-T team) was constituted for the management of CAR-T therapies (Chimeric Antigen Receptor T). The pharmacist was included in the team for the planning and organisational phase of the process.

How was it done?

The pharmacist is responsible for the approval of the physician’s prescription, the LC preparation according to Good Manufacturing Practice (GMP), the LC distribution on scheduled time, the making available of treatments for supporting the patient until CAR-T infusion, and treatments after infusion for management of adverse events. At the arrival of the CAR-T product, the pharmacist is responsible for the check and release of it in good condition. The LC protocols foresee the administration of cyclophosphamide and fludarabine on the 5th, 4th and 3rd day before the CAR-T infusion, and are defined on the basis of the summary-of-product characteristics. The medications are provided locally and refunded by the national health system.

What has been achieved?

In our center 8 patients were treated with compassionate use of axicabtagene ciloleucel. The pharmacist’s presence in the multidisciplinary team was advantageous because, through validation of the therapies and verification of dosages, they guarantee further security to the patients. The high-tech automated centralisation and computerisation of chemotherapies at our centre ensured quality and safety of the preparations.

What next?

The realisation of defined paths and codified proceedings, the respect of fundamental timings for the success of the process and the chemotherapy preparation centralisation could lead to increased investment, decisive for obtaining a high quality product and process level. The experience, now limited to haematology, could be used for future CAR-T applications.

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Author(s)

Marinos Petrongonas, Maria Fragiadaki, Eleni Rinaki, Leonidas Tzimis

Why was it done?

Implementation of antimicrobial stewardship programmes in hospitals is part of the national strategy to promote prudent use of antimicrobials. As HPs chair stewardship teams, they are responsible for assessing prescription and monitoring antimicrobial use. Designing and developing automated informative tools facilitates HPs in their role.

What was done?

Hospital pharmacists (HPs) designed and developed software tools to support the antibiotic stewardship team’s work. Particular developments were: a) Α PC application (GrAD_calc), in Microsoft Excel, to calculate antimicrobial consumption, instead of ABC_calc tool. GrAD_calc takes advantage of the unique codes for each branded product and transforms aggregated data, provided by the Hospital Information System (HIS), into antibiotic consumption in DDDs/100 occupied bed-days. Results are presented in charts and figures, in a format that enables ease of comparative monitoring over time. b) Necessary indexes of the above calculator and documentation needed as justification for restricted antimicrobials dispensing have been integrated into the HIS; in result, data for national surveillance programme for antimicrobial consumption are automatically exported. Useful information for pre- and post-prescription review, like demographics, indication(s), co-morbidities, current and previous treatments, microbiology tests’ results, susceptibility reports, is available and easily accessible to prescribers, HPs, and infection disease specialists.

How was it done?

HPs created GrAD_calc on their own resources, while changes in HIS were made by ICT service provider, following technical specifications described by HPs. A number of technical problems have been resolved with the contribution of HPs.

What has been achieved?

• Monitoring of antimicrobial use by pharmacy is quicker and effortless. • Handwritten documentation included in restricted antimicrobials’ prescriptions has been replaced by an electronic decision support system, as tool to improve antimicrobial prescribing and stewardship. • Useful information from patient’s medical record is directly available to HPs and physicians, and facilitates hospital’s policy for assessing antimicrobial prescriptions. • Data, like indication, medicine, dosage scheme, microbiology results and susceptibility reports, are recorded electronically and update patients’ pharmaceutical records, permitting further use for pharmaco-epidemiology studies. 

What next?

Next challenge is wide use of tools developed, to optimise pharmaceutical services provided and dispense restricted antibiotics only when accordingly justified. GrAD_calc is applicable in hospital setting and HIS’s tool is incorporated and can be used by all regional hospitals.

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Author(s)

Matts Balgård, Maria Swartling, Srebrenka Dobrić, Lena Klarén, Lina Karlsson

Why was it done?

ITWP for healthcare students is established at various teaching hospitals. However, to our knowledge, no such programme in Scandinavia has included pharmacy students. Clinical pharmacy is a growing profession in Sweden and other healthcare students will in the future work alongside clinical pharmacists. Therefore we set out to add pharmacy students to the ITWP team, believing that it would be a valuable experience for them to collaborate and share knowledge with students from other healthcare professions. Equally important, it is a way to promote the pharmacist’s competence and contribution to the multiprofessional healthcare team, prior to graduation.

What was done?

Final year undergraduate pharmacy students, specialising clinical pharmacy, were given the opportunity to spend two weeks of their six months pharmacy practice to participate in an interprofessional training ward placement (ITWP) together with medical, nursing and physiotherapy students. During this two-week clinical placement, the students were collaboratively responsible for managing the care of geriatric inpatients while under supervision of licensed practitioners.

How was it done?

A working group was formed consisting of teachers from the faculty of pharmacy, a student representative and a working clinical pharmacist. The group developed the initiative, including among other things, prerequisites, an evaluation plan, a workflow tool for clinical rounds, and suggested tasks for pharmacy students during the placement.

What has been achieved?

The programme has been running for three semesters and 6–8 pharmacy students have participated in the ITWP each semester. The initiative has been evaluated using surveys. Participating pharmacy students expressed gaining new knowledge and better insight into nursing care and the roles of the other professions. Nursing students appreciated the support in medication management and medical students found the pharmacy students to be valuable discussion partners that could challenge their drug-related decisions. Tutors expressed that the pharmacy students brought a beneficial dynamic to the ITWP team.

What next?

The opportunity for students from different professions to work together with a common objective in a real-life setting gives them valuable insight into each other’s professional roles early in their careers. This good practice initiative could be used in other interprofessional training ward placements wishing to involve pharmacy students.

Author(s)

Agnes Ann Feemster, Nicoletta Zallocco, Carlo Polidori

Why was it done?

Development of pharmacy education on a global scale is an international initiative. Additionally, employers recognise that global experiences positively impact a variety of applicant qualities, including curiosity, willingness to take risks, a non- judgmental attitude, and a broader worldview. The goal of this collaboration is to expose students to the medication distribution system and role of the pharmacist in an international practice setting with an aim of developing a more well-rounded, culturally aware pharmacist.

What was done?

A partnership between the University of Camerino (UNICAM), Camerino, Italy and the University of Maryland School of Pharmacy (UMSOP), Baltimore, Maryland, USA was formed. Under the agreement, the two universities exchange student pharmacists for five-week internships in hospital pharmacy.

How was it done?

A memorandum of understanding was implemented between the two universities in May 2018 with the first UMSOP student visiting in September 2018. A professor from each university co-coordinates the internship. UMSOP students self-fund travel while UNICAM students self-fund and seek university support; funding is a barrier to pursuing the experience. Housing logistics for the students is also challenging. UMSOP students receive academic credit for the experience, requiring that the Italian site meet the advanced practice experience objectives.

What has been achieved?

The programme intended to exchange one-two students annually. After the inaugural student, eight UMSOP students pursued the UNICAM internship, resulting in six student placements at three Italian hospitals. One UNICAM student pursued a cardiology experience at an academic medical centre in Baltimore. UMSOP students perform a preceptor and site evaluation after the internship. 100% of students completed the evaluation with an overall evaluation score of strongly agree that the preceptor and site provided a positive experience. A structured interview with the UNICAM student indicated a greater understanding of clinical pharmacy practice and the role of a pharmacist on an interdisciplinary team, which may be used to further develop hospital pharmacy services in Italy.

What next?

This international exchange demonstrated a high degree of satisfaction among participants. While currently limited to students, this initiative should be considered for practising pharmacists. Sharing of best practices and the interchange of ideas may generate practice enhancements, lead to innovations, and stimulate personal growth.