Medical treatment of high blood pressure in patients with ileostomy
European Statement
Clinical Pharmacy Services
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.
Obtaining patient feedback via a forum group
European Statement
Clinical Pharmacy Services
Author(s)
Ishrat Saddiq Ali, Gemma Harris
Why was it done?
The idea behind setting up this group was inspired by passionate Pharmacy Team members who wanted to ensure that the Department was abiding by the Trust’s promises and standards for patient care, making sure that patients feel welcomed, cared for and in safe hands, and to raise the profile of the work carried out by the Hospital Pharmacy Team.
What was done?
In October 2014, the Pharmacy department set up a Pharmacy Patient Forum Group (PPFG).
The main aim of PPFG was to discuss ideas and share experiences from patients to support the Pharmacy Department, regarding implementing new changes to enhance patient safety and experience. This would support in delivering the Trust’s objectives for becoming best in class for patient experience.
How was it done?
Meetings are arranged approximately every 6 weeks and attended by:
• Trust Membership and Engagement Manager
• Pharmacy staff – Senior Pharmacist and Ward Based Services Technical Manager
• Trust members
Patient representatives were given a complementary tour of the Pharmacy Department where they could see the workforce in action and appreciate the workload of the team. The tour included:
• Dispensary
• Aseptic Unit
• Out of hours Medication Area
• And a visit to the Admissions ward where they saw the Ward Based Pharmacy team in action.
What has been achieved?
Several projects are being carried out simultaneously. The main project arose when patient representatives raised concerns about correctly identifying indications of medicines due to polypharmacy. We have designed a universal sticker images to enable patients to identify indications when faced with language barriers or vision problems. We have successfully developed a cardiology, indigestion/heartburn and pain specific sticker.
We have gained approval from other specialities regarding the images.
Another project focussed on tackling patients’ negative perceptions about discharge delays regarding medication. Patient representatives were invited to view the MEDI-365 automated dispensing machine which are utilised by Ward Based Clinical teams. This led to patient representatives viewing the pharmacy Prescription Tracking System (PTS) which is used to provide live information to all ward staff about pharmacy workload and track patients’ medication. The PTS has been further refined to produce a label which is attached to discharge medication detailing the time taken to process the prescription.
Patient representatives reported that they welcomed the opportunity to see a Pharmacy Department functioning within a busy District General Hospital
What next?
• We are looking to involve local primary schoolchildren/college students in the design of future images. This will aid in helping strengthen local community relations and raise awareness of the projects.
• We are currently working on producing a Discharge Leaflet explaining the Pharmacy Discharge Pathway.
• We find it extremely beneficial to meet via PPFG. We are keen to pursue with these meetings so we can work in collaboration on future initiatives to improve patient experience and safety
We have currently showcased our work in the following:
• Article published in Membership Connect Magazine in September 2015
• Article published in the PJ recently(http://www.pharmaceutical-journal.com/opinion/correspondence/obtaining-patient-feedback-via-a-forum-group/20201596.article)
• Presentation given to ‘Friends of Expert Patients Programme’ September 2016
• We have submitted an application to West Midlands Innovation Day to consider our work
• Article published in the Trust Connect Magazine in October 2016
A PHARMACIST IN THE MULTIDISCIPLINARY ONCOLOGY TEAM
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Ulrike Guger-Halper
Why was it done?
The pharmacy of the hospital supplies four hospitals with cytotoxic infusions. In the past it was found that the integration of a pharmacist in the oncology team brings benefits.
What was done?
Integration of a pharmacist in the oncology team
The aim was to evaluate the participation of a pharmacist in the multidisciplinary oncology team. The team consists of the clinical pharmacist, medical oncologists, residents, oncology nurses, dieticians, medical documentation assistent and a clinical psychologist.
How was it done?
Data were collected from May 2014 to September 2015.
All chemotherapy protocols were electronically prescribed in CATO® (computer aided therapy for oncology) and included cytotoxic drugs and concomitant medications.
In addition to production in the cytostatic unit the pharmacist participated in the daily morning meetings, the two-week tumor boards and bimonthly team meetings.
Pharmacist interventions (PI) took place during the meetings and were also communicated by phone and mails.
What has been achieved?
3335 cycles of chemotherapies were prescribed and 914 interventions were recorded.
CATO®-related PI (33,3%) were categorized in: literature research (4,7%), chemotherapy protocols (3,2%), dose selection (16,7%), treatment duration (1,4%), application/infusion time (0,9%) and others (6,4%).
Not CATO®-Related PI (66,7%) were categorized in: logistics (24,2%), patient-related (26%), drug-related (16,5%)
Under pharmaceutical participation: 15 guidelines, 1 abstract for a poster presentation, 27 work tools, 2 workshops, 2 publications, 1 lecture, 15 staff trainings, wipe samples in preparation
What next?
In this observational study we demonstrated the significant role of the clinical pharmacist as a part of the multidisciplinary oncology team. The supply by a pharmacist means to optimize treatment protocols and procedures and improving patient safety.
Medication errors occur despite electronic prescription of standardized protocols. Clinical pharmacists with special experience in oncology play an important role to identify errors in oncology.
A plausibility check by a pharmacist is still needed.
References: Sessions J. K. et al., Role of Oncology Clinical Pharmacists in Light of the Oncology Workforce Study, J Oncol Pract. 2010 Sep; 6(5): 270–272.
INFLUENCE OF INTEGRATION OF A PHARMACIST IN MEDICATION ERRORS IN CRITICALLY ILL PATIENTS
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
A. Valladolid-Walsh, E. Domingo-Chiva, P. Cuesta-Montero, J.A. Monsalve-Naharro, E.M. García-Martínez, S. Plata-Paniagua, M.D. Pardo-Ibañez, G. Romero-Candel, J.M. Jiménez-Vizuete, R. Peyró-García
Why was it done?
To determine the incidence of medication errors in our environment and implement enhancement systems to prevent them, which is a priority for the improvement of the drug treatment process in critically ill patients.
What was done?
A clinical pharmacist was integrated on a full time basis into the multidisciplinary team of an anaesthesia intensive care unit (ICU).
How was it done?
The project was carried out in 3 different stages:
– First stage: a prospective observational study was carried out over 1 month to detect medication errors in anaesthesia ICU and to determine the baseline situation before the pharmacist´s intervention. During this stage, 36.27% errors were detected in overall treatments.
– Second stage (intervention stage): Over 10 months, the pharmacist reviewed the prescriptions of all patients admitted to the anaesthesia ICU, performing the appropriate interventions regarding medications. Furthermore, to educate physicians and nursing staff, we organised educational meetings, and also pharmacotherapeutic protocols and guidelines of medication administration were created to standarise clinical practice. Finally, a system for reporting medication errors was introduced.
– Third stage: a prospective observational study was carried out for 1 month to detect medication errors after the pharmacist’s intervention. During this stage, 5.9% of errors were detected in overall treatments.
What has been achieved?
– Medication errors were reduced by more than 30%.
– A pharmacist is now part of the multidisciplinary team in the ICU.
– The experience has been broadcast to the national level to promote the implementation of clinical pharmacist activities in our environment.
What next?
We are still working on the same areas to improve safety in drug therapy in critically ill patients. Currently, improvement measures that are being developed are: new pharmacotherapeutic protocols specifically for this unit; drugs and drug-diluent compatibility guidelines; new training sessions; standarised medication kits in operating rooms and implementation of the computerised prescription; and a new labelling system for syringes.
IMPLEMENTATION OF A SAFETY AND HEALTH PROGRAMME FOR THE MANAGEMENT OF PATIENTS WITH HEPATITIS C RECEIVING TREATMENT WITH DIRECT ACTING ANTIVIRAL AGENTS
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
S. IBAÑEZ GARCIA, C.G. RODRIGUEZ-GONZALEZ, A. GIMENEZ-MANZORRO, E. CHAMORRO DE VEGA, R. COLLADO-BORELL, E. LOBATO-MATILLA, A. DE LORENZO-PINTO, M. TOVAR-POZO, A. HERRANZ-ALONSO, M. SANJURJO-SAEZ
Why was it done?
CHC affects approximately 3% of the world’s population. The development of well tolerated and effective AADs has changed the therapeutic landscape. These therapies have a high efficacy with a good safety profile. Numerous challenges in terms of patient education, monitoring, medication errors, drug interactions and adherence exist. Our National Health System launched a strategy plan for proper CHC management in April 2015, establishing, among other things, measures to optimise AAD use.
What was done?
We have developed a pharmaceutical care programme.
I. The following protocols were defined:
– A case selection and treatment guideline, following the recommendations from health authorities.
– A protocol for the management of drug interactions.
– A protocol with recommended dosages and administration techniques.
– A protocol with potential adverse drug events and recommendations about how to prevent and manage them.
– A protocol about clinical interview to ensure patient literacy and co-responsability.
– Patients information leaflets.
II. The pharmacy department was provided with:
– 3 full time pharmacists.
– 2 patient information offices.
– a queue management system.
III. Appointment scheduling:
Pharmacy visits were scheduled after the hepatologist/infectious disease specialist appointments every 28 days.
IV. The clinical interviews were documented in the electronic health record.
How was it done?
A multidisciplinary team was formed with two hepatologists, one infectious disease specialist, three clinical pharmacists and one nurse to:
– Address the key points associated with the safe and efficient use of AADs.
– Create a useful clinical guideline.
– Identify staffing and logistics needs.
What has been achieved?
No of patients included in the programme: 674
No of initial visits: 674
No of follow-up visits: 1750
No of patients attended/day: 19.9
No (%) adherent patients at the end of treatment: 412/412 (100%)
No of pharmacist interventions: 195
No (%) pharmacist interventions accepted: 194 (99%)
Average waiting time to be attended by the pharmacist: 15 min
No of queries made to the hospital pharmacist: 84
No of adverse drug events reported to the pharmacovigilance centre: 31
Cost savings (€): 121 194
What next?
This initiative provides a set of recommendations regarding CHC management and a support guide to standardise and guarantee high quality pharmaceutical care.
The next step is to develop pharmaceutical care programmes for the management of other pathologies following the same methodology that we have used for this initiative.
Medication reviews conducted by clinical pharmacist in emergency ward
Pdf
European Statement
Clinical Pharmacy Services
What has been achieved?
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CONTINUITY IN PERIOPERATIVE MEDICATION MANAGEMENT
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
A. Navarro-Ruíz, C. Matoses-Chirivella, J.M. Del Moral-Sánchez, M. Morante, F.J. Rodríguez-Lucena, R. Gutiérrez-Vozmediano, A. Martínez-Valero, A. Andújar, E. García-Iranzo, A. Martí-LLorca
Why was it done?
There is evidence of discontinuity medication between different health care levels. In fact, on admission to hospital, up to one in two patients has an incomplete medicine list , resulting in a medicine not being administered during the hospital stay. This situation could be associated with an increased risk of hospital readmission or adverse drug reaction (ADR). Some studies show that an elevated percentage of surgical patients take medications prior to surgery, cardiac medications principally, but almost 50% of the drugs are omitted on the day of surgery.
What was done?
To develop a guideline to achieve the continuity of quality use of medicines between hospital and community in surgical patients.
How was it done?
The lack of medical evidence is reflected by the large variation in perioperative management recommendations among several group of experts. The recommendations in this guideline are to a large degree expert opinion, based on information from other reviews and textbooks, along with clinical experience. After a thorough review, the guide has obtained the consent of the Commission of pharmacy and therapeutics of the hospital.
What has been achieved?
The guide of conciliation of the medication includes a medication review structured according to the classification made by WHO ‘Anatomical, Therapeutic, Chemical classification system’. In each one of them, including the benefits and risks of continuing with this therapy during the perioperative process. It also includes various annexes, on antihypertensive, glucocorticoids and medicinal plants.
What next?
In the future, we would recommend prioritising the conciliation to the discharge with respect to other points of transition assistance, since the potential severity of an error of conciliation not intercepted the discharge of the patient is greater than if it occurs within the hospital.
INTEGRATED ONCOLOGY PHARMACY UNIT IN MULTIDISCIPLINARY TEAM
Pdf
European Statement
Clinical Pharmacy Services
Why was it done?
There was a previous collaboration between the pharmacy and medical oncology but with many problems due to the physical separation between the two units. There was a lack of knowledge of the needs of both services.
What was done?
To provide integral cancer care to the patients. We prepare the standard or investigational treatments the day of analysis and medical consultation. In the pharmacy consultation, we provide information and training to patients and their caregivers about the use of antineoplastic, evaluate their polytherapy and complementary and alternative therapy, drug interactions, conciliation, dispense doses and adjusted to help improve treatment and adherence and tolerance amounts.
How was it done?
Change of hospital, creation of new onco-hematology unit(2003), good feedback, and integration in clinical sessions.
What has been achieved?
The pharmacist reviews each chemotherapy order in relation to all known factors concerning the patient. If questions arise, the physician originating the order is contacted. Orders are verified with a protocol, standard regimen or standard dosing guidelines. The oncology pharmacist contributed to the design of chemotherapy protocols by electronic prescribing program (Farmis_Oncofarm®) and supportive care protocols. Activity (2013):22.770 preparations of intravenous chemotherapy, 9.651 patients consulting pharmacy. Reusing cytostatics in a centralized pharmacy preparation unit (Nplate®saving:129.910€(31.7%)), the preparation of parenteral mixtures at the pharmacy department minimises costs compared to preparation on wards (estimated saving 2.500.000€).The unit is also actively engaged in clinical trials (166 trials) and other research projects (pharmacogenetics and adherence with electronic monitoring system) with several publications (∑IF=84). It is a reference model clinical and teaching, oncology pharmacy unit is a preceptor to residents, staffs of other hospitals. Realisation of the annual attendance course. Unit Growth: 2 oncology pharmacist(BCOP),1 haematology pharmacist (BCOP),1 paediatric pharmacist, 3 nurses,1 technician and 1 investigator. Implantation of Standard UNE 179003 on Risk Management for Patient and ISO9001. 0.5 % errors and avoiding incidents. High average patient satisfaction(93%).
What next?
Allow direct patient interaction through a econsultation platform and twitter. A staff preceptorship and traceability system for the preparation and administration(barcode) implement.