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ANTIMICROBIAL STEWARDSHIP: WHAT IF EVERYTHING IS ON YOUR SCREEN? (submitted in 2019)

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European Statement

Introductory Statements and Governance

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 • Handwritten documentation included in restricted antimicrobials’ prescriptions has been replaced by an electronic decision support system, as tool to improve antimicrobial prescribing and stewardship.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.

INCLUSION OF PHARMACY STUDENTS IN AN INTERPROFESSIONAL TRAINING WARD PLACEMENT FOR HEALTHCARE STUDENTS IN SWEDEN (submitted in 2019)

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European Statement

Education and Research

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.

DEVELOPMENT OF AN INTERNATIONAL EXCHANGE PROGRAMME IN HOSPITAL PHARMACY PRACTICE (submitted in 2019)

European Statement

Education and Research

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.

PROMOTING THE USE OF SAFER INJECTABLE MEDICINES USING A NOVEL METRIC

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European Statement

Patient Safety and Quality Assurance

Author(s)

Gillian Cavell

Why was it done?

Despite the availability of RTU and RTA formulations of high-risk injectable medicines they were not always used. We developed the metric, to compare the use of RTU and RTA injectable medicines with the use of concentrates requiring further dilution or manipulation prior to administration e.g. dilution of morphine 10 mg/ml to 10 mg/10 ml prior to intravenous administration, e.g. withdrawal of 5 x 10 ml fentanyl 500 mcg/10 ml into a 50 ml syringe for continuous infusion, and identify areas for improvement.

What was done?

We have developed a series of metrics to measure compliance with national guidance for the safe use of injectable medicines. The guidance recommends use of ready-to-use (RTU) or ready-to-administer (RTA) injectable products, where these are available, to reduce the risk of patient harm from errors in the preparation of injections and infusions on hospital wards.

How was it done?

The metric utilises pharmacy-issue data to compare the number of units of RTU or RTA formulations issued to wards and clinical areas with the numbers of units of alternative products of the same drug entity. Expressed as a percentage the metric informs the organisation of the extent to which safer injectable medicines are being used, providing a baseline against which to review practice and reinforce the need to use alternative, safer formulations. A high percentage indicates good compliance.

What has been achieved?

The metrics have been used to successfully maximise the use of a range of safer formulations including RTA potassium chloride, RTU fentanyl 2500 mcg/50 ml vials for critical care infusion, 100 mg/10 ml paracetamol in neonatal units and RTU magnesium sulphate 20% (50 ml vials) for obstetric emergencies. Since the introduction of the metrics in 2016 a monthly scorecard of performance is reviewed by the Hospital Medication Safety Committee to identify and account for deviations.

What next?

The metrics are being shared with other organisations to benchmark performance. Ideas to promote implementation and business cases can be shared between organisations who may find implementing RTA and RTU injectable medicines challenging, especially where these are more expensive than formulations in established use.

INTEGRATION OF THE CLINICAL PHARMACIST IN A MULTIDISCIPLINARY TEAM IN A BURNS UNIT

European Statement

Clinical Pharmacy Services

Author(s)

Ángel Guillermo Arévalo Bernabé, Pilar Lalueza Broto, Jordi Serracanta Doménech, Jacinto Caparrós Baena, José Manuel Collado Delfa, Jordi Aguilera Sáez, Romy Rossich Verdés, Pablo Sánchez Sancho, Juan Carlos Juárez Giménez, Maria Queralt Gorgas Torné

Why was it done?

The burns unit of a third-level hospital includes a patient’s great heterogeneity depending on his population group and his clinical condition (extension, degree and depth of his burns, etiological agent of the burns and associated comorbidities), which makes the managing of these patients complex and they need multidisciplinary solutions. In addition, extensive burns provoke physiopatological alterations that involve changes in the pharmacokinetical and the pharmacodynamical modelling of some drugs. The knowledge that the pharmacist has about the changes that take place in vascular dynamics, the clearance and the distribution volume of the drugs, and the degree of union from these to plasmatic proteins, makes his active participation in the care of the burns patient, and in the optimisation of his pharmacotherapeutic plan, very interesting.

What was done?

The integration of the pharmacist into a multidisciplinary group of assistance to the burns patient constituted as the Managing Committee of Cases and was integrated by plastic surgery, intensive medicine, intensive paediatric medicine, preventive medicine, infectious diseases, psychiatry, psychology, social work and infirmary, as well as pharmacy.

How was it done?

A protocol was devised that standardises and systematises the review of the pharmacotherapeutic plan of all patients in the burns unit, including burn critical and paediatric. Also, there is included a model of record and codificate of pharmaceutical interventions. The multidisciplinary group meets weekly and every patient is analysed from all clinical points of view, the pharmacist intervening in relation to the pharmacotherapeutic and nutritional plan.

What has been achieved?

The active integration of the pharmacist has been achieved in the clinical group of assistance to the burns patient. In addition, there has been created a collaborative attitude that has benefited joint projects of investigation. The degree of acceptance of the offers of modification that the pharmacist realises is 90%.

What next?

The following step must be, depending on the obtained results, to establish improvement assistance measures, including the accomplishment of protocols and the development of investigation projects that help to generate knowledge about the use of some drugs in burns patients, such as immunoglobulin or proteolitic enzymes for the extraction of bed sores.

THE PHARMACIST IN THE LUNG CANCER MULTIDISCIPLINARY TEAM

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European Statement

Clinical Pharmacy Services

Author(s)

Ana Soares, Armando Alcobia

Why was it done?

Several clinical practice guidelines for LC recommend that multidisciplinary teams should be used to plan patients’ treatment. The evolution of thoracic oncology, namely the increasing knowledge of the diverse histologic and molecular phenotypes in non-small cell LC, has been driven to more complex treatment algorithms in recent years. This complexity increases the need for a multidisciplinary approach in therapeutic decision-making, which must be individualised and based on the best information available. The pharmacist’s inclusion in the multidisciplinary team is essential and was formerly proposed by the Pneumology Director to the Hospital Administration Board.

What was done?

A hospital pharmacist is a permanent member of the lung cancer (LC) multidisciplinary team, which has met weekly since January 2016, to plan the management and treatment of LC patients in our hospital. The pharmacist brings updated information about the efficacy and safety of drug treatments, its cost-effectiveness and its availability. The pharmacist improves communication with the Pharmacy and Therapeutic Committee.

How was it done?

The multidisciplinary team meets weekly to discuss the diagnosis and treatment options of LC patients, and includes a dedicated group of professionals: pulmonary oncologists, a thoracic surgeon, a radiation oncologist, a radiologist, a pathologist, a nuclear medicine specialist, a hospital pharmacist, a palliative care physician and an oncology nurse.

What has been achieved?

About 240 cases, corresponding to 200 patients were discussed per year. An average of 110 solicitations to the Pharmacy and Therapeutic Committee were made. The multidisciplinary team grants a systematic approach to diagnosis and therapeutics, in compliance with evidence-based guidelines, improves communication and coordination between professionals and short waiting times for the patient.

What next?

The next step is to systematise real-world data collecting, from the patients treated, to better understanding the effectiveness of treatment options and the real impact of the multidisciplinary team in patient outcome, ideally, extending it onto a national level.

IMPLEMENTATION OF A NEW CLINICAL PHARMACY SERVICE WITHIN A NEWLY LAUNCHED SURGICAL ADMISSIONS PROCESS

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European Statement

Clinical Pharmacy Services

Author(s)

Dora Mueller, Maria-Theresia Pichler, Karin Kirchdorfer, Kora Koch

Why was it done?

Prior to the implementation, insufficient time resources did not allow for clinical pharmacy services (CPS) on all surgical wards. Existing cover was not efficient or effective as drug-charts were often not available or patients discharged before pharmacy suggestions were implemented. The integration of the CPS into the centralised admission process instead of the wards resolved these shortcomings and facilitated pharmacy input to all surgical patients using this admission process.

What was done?

A central surgical admissions process was launched at a 450-bed teaching-hospital in April 2018 in which patients are seen five days before surgery by an interdisciplinary team. A new clinical pharmacy service (CPS) was implemented on-site to review patients’ medical history comprising three consecutive steps:
1. Medicines reconciliation is completed based on existing patient-consultation records.
2. Recommendations for switching drugs to the hospital formulary on admission are noted on the drug chart.
3. Medication review is carried out to improve inpatient medication safety, and changes are communicated to medical staff via e-consult.

How was it done?

This proactive concept highlighting the advantages of interdisciplinary CPS and reflecting international evidence (e.g. patient safety, patient care, workload reduction for medical and nursing staff) convinced hospital management of its need. Resource implications included allocation of a pharmacy office on-site, development of a standard operation procedure and support for interdisciplinary teamwork on-site.

What has been achieved?

Between April and September 2018, records of all patients using the new process (n = 1527) were reviewed by a clinical pharmacist. At least one drug-related recommendation was made for 38.6% (n = 589) of all patients taking medication. This development enhances the clinical pharmacy workforce at our hospital and contributes to the quality of the admission process. Feedback from medical and nursing staff, hospital and quality management was positive throughout. We observed an improved level of awareness, higher numbers of requests for other CPS and a better understanding of the clinical pharmacists’ role within the healthcare team.

What next?

This initiative reflects how CPS can be expanded and optimised by seizing the opportunity and using existing resources. This model may be adapted for other hospital inpatient settings.

ANTIDOTES NETWORK BETWEEN PHARMACY DEPARTMENTS IN SPAIN

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European Statement

Selection, Procurement and Distribution

Author(s)

EDURNE FERNANDEZ DE GAMARRA MARTINEZ, NÚRIA PI SALA, RAQUEL AGUILAR SALMERON, ANTONI BROTO SUMALLA, MILAGROS GARCÍA-PELÁEZ, LIDIA MARTINEZ SÁNCHEZ, SANTIAGO NOGUÉ XARAU

Why was it done?

Antidotes are drugs used in emergency situations. Some of them often present availability issues due to shortages, high cost, complex acquisition (foreign drugs’ importation) or short validity periods. This tool was implemented in July 2015 to improve the availability of antidotes.

What was done?

A virtual network was designed in order to have a tool that allows pharmacy departments to locate antidotes: to know in which centres they are stocked, how much there is of each drug and when it would expire. It also facilitates communication between centres and loan movements in case they are required.

How was it done?

A web-based application was developed (www.redantidotos.org). It includes a public site with general information, an updated antidotes guide and a section where non-urgent toxicological consultations could be submitted. In addition, there is a private site (accessed through username and password) where each pharmacy department might introduce the stock they have of 18 selected antidotes (anti-digoxin antibodies, anti-vipera serum, botulism antitoxin, dantrolene, deferoxamine, defibrotide, dimercaprol, calcium disodium edetate, ethanol, fomepizole, glucagon, glucarpidase, hydroxocobalamin, idarucizumab, pralidoxime, physostigmine, silibinin and uridine triacetate). Each Hospital has two key users: a ‘farmatox’ (pharmacy department) and an ‘urgetox’ (emergency department). Their participation has been crucial for the success of the project.

What has been achieved?

Currently there are 63 Spanish hospitals included in the Antidotes Network. It has been used 49 times to locate an antidote that was needed and to request a loan between centres. Thirteen antidotes were involved in these movements. The most requested drugs have been anti-vipera serum (10/49), glucagon (6/49), anti-digoxin antibodies (5/49), botulism antitoxin (5/49) and fomepizol (5/49). Additionally, recommendations were published about stock availability and use of antidotes according to hospital complexity (Emergencias 2016;28:45-54).

What next?

The network was first implemented in Catalonia and now the project is being extended to other Spanish regions (currently it has been implemented in three out of 17 regions). We aim to continue improving communication between professionals involved in intoxication management, sharing knowledge and improving the care we offer to our patients.

ANTIMICROBIAL STEWARDSHIP ALERTS SYSTEM

European Statement

Patient Safety and Quality Assurance

Author(s)

Emma Ramos Santana, Enrique Tevar Alfonso, Maria Jose Castillos Mendez, Maria Luz Padilla Salazar, Lucy Abella Vazquez, Jesus Ode Febles, Marcelino Hayek Peraza, Javier Merino Alonso

Why was it done?

The implementation of an antimicrobial stewardship program (AMS) is very important, but it has to be accompanied by personal resources. It is therefore necessary to effectively use the time spent in the AMS.

What was done?

We have worked with the Information Technology Service to develop an “Intelligent Antimicrobial Screening Program” (IASP).

How was it done?

Using the information available in Electronic Health Record (EHR) and in pharmacy and microbiology applications we have developed a computer tool that analyze hundreds of situations through pre-established conditions

What has been achieved?

Currently the system analyzes more than 40 conditions related to the correct use of antimicrobials based on antibiotic characteristics, patient situation and microbiological data.
Some of the most relevant conditions are:
●Antibiotic prescribed more than 6 days.
●Patient with parenteral antibiotic for more than 3 days and with other oral medicines.
●Antibiotic that must be adjusted in patients with renal impairment prescribed in patients with glomerular filtration rate (GFR)65 years old, GFR5 days prescribed or other nephrotoxic prescribed.
●Patients with linezolid and thrombocytopenia or anemia or without an hemogram in the last week.
●Patients with daptomicyn and high creatininkinase (CK) or without a recent determination.

What next?

This software allows to collect information contained in different systems and displays it in an organized view to the user. This makes it an easily system that can be exported to other hospitals.
Our next objective is to consult the microbiological information. Therefore the system will be able to recommend about the optimal antimicrobial treatment, detecting situations in which the treatment can be de-escalated or alerting in case of resistance.

INTRODUCING A CLINICAL PHARMACY SERVICE INTO THE HOSPITAL EMERGENCY DEPARTMENT AT THE WEEKEND

European Statement

Clinical Pharmacy Services

Author(s)

Roisin O’Hare, Andrew Dawson, Natasha Beattie, Eva McRory, Jayne Agnew, Sara Laird, Tracey Boyce, Victoria McConville

Why was it done?

In November 2016, regional funding was provided to all of the Trusts in order to improve medicines reconciliation rates within 24 hours of admission. The weekend clinical pharmacy service to the emergency department was established from 1st December 2016.
The aim of this project was to examine the impact of a clinical pharmacist led weekend service on to the Emergency Department in xxxxxxx.
Objectives
To determine the number of medication histories and medicines reconciliation completed within 24hrs of patient admission
To evaluate the type and signficance of pharmacy interventions identified
To record the number of medications prescribed by the pharmacist.

What was done?

A pharmacy service to optimise medicines use and pharmaceutical care for patients in the emergency department at the weekend was established.

How was it done?

We conducted a literature review on the existing clinical pharmacy services to ED. We used an Agile methodology. We established a core stakeholder group to develop a vision and a plan for the project. We used an Agile methodology with Plan Do Study Act (PDSA) with weekly ‘scrums’ and 6-8 weekly sprint meetings. We developed a data collection form to collate quantitative data; including the number of; patients reviewed by the pharmacy team, medication histories completed, medicines reconciliation completed within 24hrs of admission, pharmacist interventions, medications prescribed by the pharmacist.

What has been achieved?

We demonstrated an increase in the number of patients reviewed per day since December (average of 10) to June (average of 12). We increased the Medicines Reconciliation rate in the ED in xxxxxxx within 24hrs of admission from 0% in Nov 2016 to ~60% in Dec 2016 and ~80% in August 2017. The Pharmacy Team made on average 4.5 interventions (range 3-6) per patient reviewed (an average of 45 interventions per day). Prescribing by pharmacists demonstrated an increase in the number of medications prescribed per patient; December (0) and August (4).

What next?

The pharmacist interventions directly improved patient safety and care. Staff in the ED have anecdotally praised the service to the Pharmacy Team and have increasingly accessed the knowledge of the pharmacist at the weekend to address medication-related problems. We believe that we shaped an approach to clinical pharmacy practice in the ED which could be shared across the Trust and further across the country.
References:
1. Medicines Optimisation, the safe and effective use of medicines. Available from: http://www.nice.org.uk/guidance/ng5 Accessed on 13th October 2017.
2. Eadon H. Assessing the quality of ward pharmacists’ interventions. Int J Pharm Practice. 1992;1:145–7.
Acknowledgements:
We would like to acknowledge the work of the entire clinical pharmacy and clinical pharmacy technician staff at xxxxxxx who provide this service to the ED at the weekend and who tirelessly collected the data for this project.

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