Author(s)

Luis Díaz Suárez, Elena Sánchez-Yanez , Raquel López Escoz, Mercedes Gómez Delgado, Nuria Martínez Casanova, Isabel Moya Carmona

Why was it done?

The hospital pharmacist plays a role obtaining therapeutic success by improving the adherence. Our unit attends around 1900 HIV patients, so the interventions we make to improve adherence will have a positive impact on patients and community.

What was done?

The Pharmacy Service has developed a protocol for the identification of non-adherent HIV patients to treatment along with the pharmaceutical attendance strategies designed to improve the adherence to ART.

How was it done?

The protocol was drawn up with the recommendations of the National AIDS Plan(PNS), the Spanish Society of Hospital Pharmacy(SEFH) and the AIDS Study Group(GeSIDA). Thus, we wanted to provide a multidisciplinary approach for non-adherent patients. The relevant aspects of the protocol are described below:

1.-Identification of patients: Technical staff and pharmacists identify patients with poor adherence through dispensing records, a history of previous voluntary abandonment of ART or the presence of risk factors for poor adherence to ART.

2.-Pharmaceutical attendance following the CMO model.

· Data such as viral load, CD4, prescribed ART, pharmacotherapeutic complex index, home medication, polypharmacy, pluripathology and risk factor have
been collected. Adherence was calculated using dispensing records and adherence questionnaire(SMAQ).

· Health education and motivational interviewing.

· Personalised planning of patient care following face-to-face and non-face-to-face programs. Every 6months adherence will be re-evaluated to assess the
success of the pharmaceutical care offered.

What has been achieved?

The protocol was implemented in March-2021, and to date, 68patients have been included. 73.5%(n=50) of them have been followed for more than 6 months. 88% of whom(n=44) improved their adherence to both ART, all of them achieving an undetectable viral load and an elevation of the CD4 count.

What next?

Our desire is to continue detecting patients and to contribute to the improvement of the adherence to their treatment. We are aware of the challenge that lies ahead in the near future, as the progressive ageing of the HIV population means an increase in associated comorbidities and polypharmacy, which may have a negative impact on the adherence.

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)

Hilario Martinez-Barros, Maria Muñoz-Garcia, David Gonzalez-de-Olano, Silvia Sanchez-Cuellar, Enrique Blitz-Castro, Gonzalo De-los-Santos-Granados, Dario Antolin-Amerigo, Ana de-Andres-Martin, Patricia Fernandez-Martin, Elena Gemeno-lopez, Ana Maria Alvarez-Diaz

Why was it done?

• To understand directly and holistically the patients’ vision of their illness, treatment, healthcare experience and how they impact their daily lives.
• To define the ideal SAU by identifying innovations and changes that satisfy patients’ needs.

What was done?

ASfarMA is a hospital pharmacist-led project within a multidisciplinary Severe Asthma Unit (SAU) that aims to apply different innovative measures encompassing humanization to improve treatment related results and patient experiences.

How was it done?

Human-Centered Design (HCD) is an approach to problem-solving that aims to make systems usable and useful by focusing on the users and their needs.

A core group was constituted with at least one member from each of the specialities that are part of our SAU. Members of an HCD-team devised and contributed to organize the following activities:

• A first core group session was held in which, using different dynamics, 4 patient archetypes were identified, and the patients´ journey through the Unit was described.
• HCD-team members interviewed both SAU professionals and 8 patients who matched the previously defined archetypes. The latter was also given a patient diary designed to obtain descriptive and emotional information within the SAU.
• Utilizing the previously obtained data, a co-creation workshop was held by the HCD-team involving both the core group and the participating patients.

What has been achieved?

A series of proposed measures that respond to patients and professionals’ reported needs were made. They were classified as either “transformative solutions” or “quick wins”:

– 7 transformative solutions, which provide holistic responses that require greater development, effort and resources, were identified. E.g. Two-way communication APP, onboarding kit, design of common spaces for SAU members, patient coordinator.

– 14 quick wins, which provide significant benefits but can be implemented with lesser effort and resources, were identified. E.g. Non-urgent consultation mailbox, pediatric-adult patient transition consultation, asthma-specific emergency department circuits, coordinated consultation agendas between severe asthma unit members, expert patient workshops.

What next?

This project, which has a qualitative nature and is based on the experiences of both patients and professionals, has allowed us to understand their needs and identify innovative solutions that will be applied progressively to our SAU and other hospitals.

Author(s)

Helen Cooper, Sheatha Abumehdi

Why was it done?

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

What was done?

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

How was it done?

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

What has been achieved?

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

What next?

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

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

Author(s)

François TISSERAND, Pierre MENAGER, Alexandre NAVID, Léa ROUSSET, Adeline BANNIER, Julie MORIO, Hélène PERRIER, Elsa JOUHANNEAU

Why was it done?

The geriatricians contacted the pharmacy to deliver training courses to the geriatric residents. This has enabled pharmacists to develop a close relationship with geriatricians to offer them clinical pharmacy activities in their ward. Geriatricians were familiar with clinical pharmacy, in particular the medication reconciliation, which is used to perform the former in other hospitals. Geriatricians are concerned with iatrogenic illness and therefore see medication reconciliation and pharmaceutical analysis as a relevant approach to clinical pharmacy.

What was done?

A successful model of partnership between Geriatrics and Pharmacy has been created and developed.

How was it done?

A first meeting was held between geriatricians and pharmacists. It was decided a pharmacy resident would be dedicated to a given geriatrician. This first resident’s objectives are to follow the medical rounds and to carry out medication reconciliations upon admission and discharge. Pharmaceutical support has enabled real-time validation for the prescription of the appropriate drugs. As the internship progressed, the resident became the privileged interlocutor for a Pharmacy-Unit relationship.

What has been achieved?

To date, 37 medication reconciliations were carried out, where the resident followed 2 medical rounds per week over 17 weeks. All unintentional discrepancies were corrected (n=13). Concerning the appropriateness of prescriptions, 16 inappropriate medications were stopped. During the medical rounds, 34% of the therapeutic problems (n=35) were related to inappropriate drug according to guidelines, 17% to dosing errors, 14% to drugs without indication. More than 50% of pharmaceutical interventions were judged capable of preventing harm that requires increased monitoring or treatment or lengthening of the hospital stay (63%). During this period, 54 questions were asked and discussed between the resident and the geriatrician to improve patient care. At the geriatricians’ request, two courses were organized about non mastered topics. On the ward, the resident acted as a go-between for a number of issues such as referencing medical devices, rearranging the storage of medicines or finding the right contact person for information activities.

What next?

What has been done needs to be continued and improved. A pharmacist-geriatrician cross-training should be implemented soon. New activities with pharmacist-geriatrician interactions are being created, such as day hospitalization for falls in the elderly population and a geriatric emergency unit.

Author(s)

Elena Lee, Yue Feng Toh, Nathaniel Lim

Why was it done?

Older patients on polypharmacy are predisposed to drug related problems (DRPs). While MTM service with pharmacist involvement can reduce DRP occurrence, few have examined its impact on reducing unplanned readmissions.

What was done?

This study was designed to determine whether a pharmacist-provided medication therapy management (MTM) service can reduce unplanned readmissions through the comparison with patients receiving usual care.

How was it done?

A retrospective cohort study was conducted in Changi General Hospital. Patients present for MTM service from Jan 2016 to Dec 2019 were included in the intervention arm (n=96) while patients who attended specialist outpatient clinics were recruited as control (n=98). Index visits from the same patient within 6 months of an earlier visit were excluded. Primary outcome was the change of unplanned admission post and pre 6-month of index visit comparing intervention arm against control arm. Secondary outcomes were descriptive of DRPs identified, number of recommendations from pharmacists, types of interventions and the potential risks avoided. Primary outcome analysis was conducted with linear regression and adjusted for potential confounders.

What has been achieved?

MTM sessions resulted in the reduction of unplanned admission rate by 0.83 (95% CI: -1.31, -0.34), p=0.001, after adjusting for confounders. For patients with admission prior to the index visit, the intervention arm had statistically significant lower incidence of unplanned admission post and pre 6-month of index visit by 0.916 as compared to control group (p=0.018). There are higher number of DRPs (144 vs 2) and pharmacist recommendations (40 vs 2) were found in the intervention arm compared to control arm respectively. The most prevalent types of DRPs were ‘Non-adherence’ (80.6%), ‘Drug omission’ (5.6%), and ‘Inappropriate dose’ (2.8%). The most common potential risks avoided were increased cardiovascular risk, n=29 (22.1%), increased fall risk, n=18 (13.7%) and increased risk of fractures, n=17 (13.0%).

What next?

The study suggests that pharmacist-provided MTM service decreased unplanned readmission rate. It has improved medication safety and quality of care by identifying and resolving more DRPs.

Author(s)

CRISTINA GONZALEZ PEREZ, LUCIA GALÁN DAVILA, MARTA ORTIZ PICA, ELENA GARCIA SUAREZ, MARIA MOLINERO MUÑOZ, LIDIA YBAÑEZ GARCIA, NATALIA SANCHE-OCAÑA MARTIN, MARIA DE LA TORRE ORTIZ, JAVIER CORAZON VILLANUEVA, JOSE MANUEL MARTINEZ SESMERO

Why was it done?

Our hospital is a reference in our community for this rare disease. Since patisiran was approved, we have treated 19 patients. Due to the high cost of patisiran and the few patients treated, it is necessary to optimize patient treatments in the most efficient way.

What was done?

Transthyretin (TTR) amyloidosis is a rare disease caused by mutations in the TTR gene. These mutations alter the normal function of TTR protein, creating slowly progressive condition characterized by the buildup of abnormal deposits of amyloid in body’s organs and tissues.
Patisiran is a TTR specific small interfering RNA (siRNA) formulation in lipid nanoparticles, which has been shown to substantially reduce the production of abnormal TTR in patients with hereditary amyloidosis TTR.
With this project we look for achieve the greatest possible savings from patisiran drug without affecting the patient’s efficacy.

How was it done?

We created a working group with neurology department, to define patient’s groups according to:
– Prescribed doses (doses per patient weight; 0.3 mg/kg).
– Preparation’s losses because of the filters
– Losses of the extraction process.
– Other individual conditions as posology or personal preferences.
Patients belonging to the same group have to administrate patisiran the same days.
As the patient’s weight can change along the time, we agree with doctors and nurses to weight the patients every six months to perform doses adjustments. Therefore, every six months we should regroup the patients to optimize the most.

What has been achieved?

These clusters have made possible to reduce wasting vials and therefore to permit significant savings. We estimate around 208.115 € savings/year.

What next?

With this practice we look for a more efficient and sustainable rational health system. The savings achieved can be used to treat other patients or promote new investigations. Also, it makes possible a better healthcare team performance, working together for a better attention, health quality, security, and treatments efficiency. Monitoring weights to adjust doses and closer follow-up of patients by the different members of the multidisciplinary team are examples of the achievements.

Author(s)

Sonja Guntschnig, Aaron Courtenay, Ahmed Abuelhana, Michael Scott

Why was it done?

The service was established as part of the implementation of a new pharmacy into the hospital. The aim of this good practice initiative was to introduce multidisciplinary work on the wards and provide clinical pharmacy support for the ward personnel. Furthermore, it determined what types of clinical pharmacy interventions are needed at a rural 360-bed hospital in Austria, and assessed the physicians’ acceptance rate of the pharmacists’ suggestions.

What was done?

A new clinical pharmacy service (CPS) was introduced into Tauernklinikum Zell am See.

How was it done?

Data on 550 interventions made by one clinical pharmacist were collected by convenience sampling over a one-year period and rated on a six-point clinical significance scale. A subset of 26 interventions was rated for clinical significance by four independent physicians to determine inter-rater reliability (IRR). A two-way model inter-rater reliability analysis was performed for the four different physician assessments using SPSS to determine intra-class correlation (ICC).

What has been achieved?

Prompt acceptance rate by the physicians involved was 71.3% (392/550). In 26.9% (148/550) of all cases, the physician considered a change. The overall average score for all 550 clinical pharmaceutical interventions taken was 2.2. ICC significance scores were correlated with the pharmacist’s scores, ICC for consistency was 0.732 and 0.732 for absolute agreement, thus both can be considered as “good”. Potential for cost reduction associated with the recommended pharmaceutical changes, namely with medication being stopped or dose reduction was 32.7% (180/550) and 25.1% (138/550), respectively.

What next?

There is great potential and a definite need for the expansion of CPS in Austria. Only 15.8% of Austrian hospitals have a pharmacy department with even less offering CPS. Many countries have demonstrated the benefits of CPS in hospitals over the past 30 and more years. The need for increased pharmacist staffing in Austrian hospitals needs to be demonstrated to Austrian stakeholders.

Author(s)

Fabrizia Negrini, Giorgia Vella

Why was it done?

The aims of this project were firstly to optimize the content of the stock (choice of medicines and quantity) so that it is suitable for various potential events of different nature that may occur in the region. The second aim was to optimize the management processes in order to reduce costs.

What was done?

To manage extraordinary events (short-lasting phenomenon without contamination) in a region with 1.5 million inhabitants, the hospital pharmacy, in collaboration with a major acute Hospital, manages a designated stock containing medication that may be required during unplanned emergencies.

How was it done?

To achieve these two aims, the first step was to define which major events are possible and most likely to occur in the region. To do this we utilized a risk-based analysis of all disasters and emergencies relevant in the area that was performed by an external company that specializes in developing risk management projects in the context of civil protection1. Based on the identified events, we determined which types of injuries were more likely to occur. The medicine stock was subsequently updated and a process for minimizing the management cost was defined.

What has been achieved?

The hazards that were identified as being of particular importance for the analyzed region are likely to mainly result in blunt, perforating, and burn injuries. In collaboration with the Hospital, a list of 61 different medicines used to treat these types of injuries was established. In order to reduce costs, only drugs which were part of the main stock of the pharmacy were chosen. In this way, it is possible to exchange products with a longer shelf life from the main stock 6 months before expiring and use them without having to discard them.

What next?

In case of extraordinary events in a restricted region, the major acute hospital has an increased need for certain medicines. It is task of the hospital pharmacy to always be ready to supply them with such medicines. This is only possible if the probable emergency scenarios are well understood, and the stock and management processes are well-defined and communicated at all levels.

Author(s)

Mapi Fleury, Januska De Maria-Lee, Alessandra Taiana, Yvan Bourgeois, Sophie Voruz, Olivier Spertini, Pierre-Yves Bochud

Why was it done?

In 2019, procedural changes within unit treating malignant haemopathies raised awareness about unsatisfactory management of NV, particularly CINV. We identified a lack of departmental consensus, leading to heterogeneous therapeutic practices, confusion over the aetiologies of NV and feelings of powerlessness among healthcare professionals. We decided to improve the whole process, from prophylaxis to treatment, by addressing specific knowledge gaps concerning CINV, improving pathophysiological and pharmacological knowledge, and implementing interprofessional management and MASCC/ESMO guidelines.

What was done?

Patient nausea and vomiting (NV)—particularly chemotherapy-induced NV (CINV) in malignant haemopathies—was managed by an interprofessional team.

How was it done?

A multidisciplinary working group was established to create a comprehensive, patient-centred NV management programme. Work sessions focussed on attaining a therapeutic consensus and adapting international guidelines to our context. Different professions learnt about each other’s needs and fields of competency, enabling each to be heard and creating mutual benefits through sharing expertise and knowledge. Pathophysiological/pharmacological leadership was given to clinical pharmacist, including developing and teaching specific protocols and supervising complex clinical situations in the field.

What has been achieved?

Interprofessional consensus was reached, documentation and techniques were implemented including clinical evaluation checklists at patient admission. CINV therapeutic regimens were completely updated and immediately and automatically included in cancer treatment protocols. The clinical pharmacist and specialist nurses give initial interprofessional training to new colleagues and ensure continuous on-site supervision. This transversal work has resulted in fewer patients suffering from NV and better team understanding of pathophysiological mechanisms, differential diagnoses and adverse drug effects—this also ended the use of unsuitable medications and dosages. Overcoming this critical situation also allowed us to begin non-pharmacological integrative care.

What next?

Interprofessional working group proved indispensable to this approach. Including CINV pharmacotherapy directly into cancer treatment plans is one of programme’s strong points and contributes to high adherence to guidelines. Team feels more relaxed and more in control. Monitoring is now done by tracking files and oral feedback, but we aim to implement systematic follow-up of interventions, care evaluations and NV to assess programme’s impact. Next stage will also include patient feedback.