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Author(s)

Krista Mikula, Silvia Hetz

Why was it done?

In the 1,200-bed teaching hospital of Wels-Grieskirchen, Upper Austria, wards place routine orders of formulary medicines online. These orders are then processed by the logistics team of the hospital pharmacy in predefined order between 6:45 and 9:00 am. Any later reorders have to be placed by telephone, leading to considerable extra time needed for processing. It is known that the interruption of an ongoing task leads to an additional 20 minutes needed to return back fully concentrated to the initial task (Besser fix als fertig: Hirngerecht arbeiten in der Welt des Multitasking, Bernd Hufnagl ISBN: 978-3-85485-331-2). The goal was to reduce time-consuming reorders by telephone to free up time for other value-adding tasks.

What was done?

At the beginning of each observation period (i.e. 3 months), the intervention wards received detailed information regarding their leading ranking position (TOP 3) and how they compared with other wards, their reorder frequency, the time-consuming impact reordering had on hospital pharmacy processes and logistical advice how to best reduce and avoid reordering. After each of the observation periods, wards with a need for intervention changed (i.e. reorders were reduced) in the TOP 3 ranking.

How was it done?

Starting in January 2014 reorders were systematically analysed across all wards by using consumption and ordering data from the hospital logistics IT system. Those three wards with the highest number of reorders received special attention as intervention wards.

What has been achieved?

The transparent information and display of those wards leading in terms of reorder frequency and quantity triggered the ambition to no longer stay among those TOP 3 wards. Starting with a total number of yearly reorders of 8,390 (2014), the intervention reduced reorders to 4,781 in 2017 (minus 43%). The most successful ward reduced the number of annual reorders from 472 in 2014 to 230 in 2015 (minus 51.48%). Two-hundred and twenty-nine reorders were placed in 2017 (minus 51.48%). The intervention was repeated for five observation periods and 15 wards were involved. After 1.25 years, these wards were ranked again, not because they had bad results, but because all wards had improved. This information initiative has become self-limiting, as overall reorder compliance stabilised at a low level. Considering the overall time needed for reorder processing (i.e. an average of 32 minutes per reorder, including a relevant process steps) a total of 1,950 hours per year (equivalent to 1 FTE) was freed for more value-adding tasks.

What next?

Constant re-evaluation of reorders take place to occasionally identify new needs for action.

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Author(s)

Francesca Vecchione, Melania Rivano, Patrizia Tadini

Why was it done?

The new process was developed in order to face the significant increase of ID management assigned to the Pharmacy, along with the logistic problems due to the several areas of storage, dispensing and administration. Additionally, it allowed to assure the effective use of ID reducing the risk of failure and improving the patient safety.

What was done?

The Good Clinical Practice guidelines establish that the principal investigator (PI) can delegate the investigational drug management to a pharmacist. In our university teaching hospital with a large amount of clinical trials (CT), pharmacy service proposed an optimisation of ID (investigational drug) management through the elaboration of a form to request the ID. Along with this, we assigned each protocol to a specific type of management and we created an intranet site from where healthcare professionals can download the form.

How was it done?

The pharmacy service created for each CT a specific form organized into 5 sections. Section A, B and C were filled up with protocol information (name, centre code, PI) patient data (initials, patient code) and the treatment schedule. Section C, completed by data manager, showed the quantity of drug to be dispensed and the expected day of administration. Section D was completed with batch and expiry date. The form had to be signed by the pharmacist at the moment of the dispensation and signed back by the committed person who took it. Section E reminded the type of management assigned to the protocol. Five different types of management had been identified, based on the characteristics of storage, the activities required by the protocol (IWRS, unblinded pharmacist, drug preparation) and the dispensing method.

What has been achieved?

Data from January to June 2017 attested 60 ongoing protocols, 722 dispensations for patient, 237 drugs prepared by pharmacists and 986 in Chemotherapy preparation unit. The development of the new procedure ensured the ID tracking, the overcoming of logistical difficulties and an increase of the safety.

What next?

We are going to keep on improving the pharmacist role in CT by ensuring ID are handled, stored and correctly managed. The objective is to enhance the collaboration of clinical research professionals in the management of CT.

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Author(s)

Elise Deyaert, Hilde Collier, Pieter-Jan Cortoos, Claudine Ligneel

Why was it done?

Medication errors are often caused by insufficient knowledge among healthcare professionals. Given limited clinical pharmacists’ presence on Belgian hospital wards, a pharmacy-led MIS can efficiently provide fast, accurate and objective medication-related information.

What was done?

We implemented the first Belgian Medicines Information Service (MIS) in our university hospital. In several countries, a MIS is common in most hospitals but until our project, no such MIS was available
in Belgian hospitals.

How was it done?

Best practices were researched through literature review and site visit at Charing Cross Hospital (London, UK). Secondly, in order to customize activities, all nurses and physicians were surveyed on medicines information needs. Our MIS was set up to centrally (1 dedicated pharmacist, phone number and e-mail address) receive medication-related questions from healthcare workers with the option to request additional clinical-pharmaceutical interventions (e.g. drug review). Implementation was accompanied by mailings, posters, business cards and presentations. All enquiries were registered in the MiDatabank® (UKMi National Medicines Information) and evaluated after 4 months, together with user satisfaction.

What has been achieved?

221 respondents (113 physicians, 103 nursing) to our survey found ‘drug administration/dosing’ (79.7%), interactions (69.6%) and ‘tablet crushing’ (49.7%) major problematic topics. Physicians rated the MIS to be useful for drug review, counselling and interactions while nursing preferred support on drug administration and tablet crushing. 96.8% intended to use the MIS.
Between 09/01 and 09/05/2017, our MIS received 247 enquiries (45.5% residents, 34.0% nursing, 13.8% clinical staff). Drug administration/dose-related questions (43.3%) was the most important category, followed by drug choice/indication (10.5%) and interactions (9.7%). 80.2% were answered within 1 hour (median: 11min). 81% of users mentioned the MIS improving their knowledge, with 59% and 56% reporting positive patient outcomes and time savings. Our MIS scored high on accessibility, timeliness, comprehensiveness and quality (average 4.34, 4.29, 4.42 and 4.47 on 5-point scale). MIS activity corresponded to 0.4FTE pharmacist with an average cost of €15.4/enquiry.

What next?

Our project shows that fast and reliable medication-related information is greatly needed. For the future, this service should be organized with other hospitals as to optimally use resources, share information and increase expertise. Also providing such service to primary care and patients will have be explored.

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Author(s)

Gösta Lööf, Malin Kuno Edvardson, Jessica Loayza, Louise Furubom

Why was it done?

According to national guidelines, 60-70% of women >50 years with a fragility fracture should receive treatment to prevent further consequences of osteoporosis. In Sörmland, only about 16% of eligible patients received such treatment in 2015. To increase this number it was decided to start a coordinator-based FLS. CPs were chosen as coordinators since they were already integrated members of the health-care team at the clinic, conducing medication reviews, with the required competence to assess patients and suggest suitable medication therapy for osteoporosis.

What was done?

By initiative of the county task force for osteoporosis in the county of Sörmland, Sweden, a project with a fracture liaison service (FLS) with clinical pharmacists (CPs) as coordinators was developed in collaboration with the orthopedic clinic at one of the region´s hospital; Mälarsjukhuset.

How was it done?

The project was initiated in December 2015. The CPs were given permission to send electronic referrals to DXA to be performed and to the general practitioners (GPs) for further investigation and initiation of treatment for osteoporosis. The CPs identified eligible patients at the orthopedic ward and at the emergency department (ED). The CPs visited and interviewed patients treated at the ward while patients treated at the ED instead received a phone call or a letter, to get information regarding their risk factors. Thereafter the CPs decided how to proceed; referral to DXA, referral to a GP or no further investigation or actions. For patients treated at the ward, the CPs would discuss their findings with the orthopedist on duty.

What has been achieved?

For patients included from December 2017 to October 2016, the percentage of who received treatment has raised to at least 25%. For about 50% of the patients, a full year has not yet passed since the date of fracture so the result may still improve. According to two small surveys, the orthopedists and the GPs are very positive to the new service and want it to continue.

What next?

Because of the success, the service will be permanented and implemented thoroughout the county. Opportunities to further improve FLS have been identified continuously and changes made accordingly to reach the goal of 60-70% treated patients.

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Author(s)

Maria Kundracikova, Petra Pölzleitner, Katharina Ocko, Bernadette Aretin, Barbara Datterl, Klara Jadrna, Eva-Luise Hobl, Martin Holbik, Sonja Steininger-Salmer, Helga Fend, Gerda Laml-Wallner, Martina Anditsch, Gunar Stemer

Why was it done?

Due to limited human ressources (8 FTE) in the medicines information and clinical pharmacy department only selected wards could be provided with daily clinical pharmacists’ presence offering medication review, patient discharge counselling and ward round participation. To expand the reach of our clinical services, two further service pillars were introduced complementing the already existing services.

What was done?

The Vienna General Hospital is a 1900 bed university hospital in which patients and health care professionals have access to hospital pharmacists’ expertise via various channels. In addition to already existing services (i.e. provision of hospital-wide medicines information and clinical pharmacy services on particularly selected wards) two new services (i.e. e-pharmacy consult and a dedicated drug interactions and pharmacotherapy clinic) have recently been implemented.

How was it done?

As ward services are staff-intensive, alternatives to expand the access of patients and health care professionals to the hospital pharmacists’ expertise were examined. An e-pharmacy consult was designed, implemented, and promoted in collaboration with the hospital IT department. E-consults can electronically be requested by all wards (e.g. for medication review, patient counselling), but mainly aim at those areas which are not regularly covered by a clinical pharmacist. E-consults are executed by the medicines information pharmacist on duty. Recently, a special clinic was implemented as a collaborative project with the clinical pharmacology department addressing the specific medicines-related needs of patients with complex medication regimens.

What has been achieved?

The scope of services provided by the department currently comprises four pillars: (1) provision of medicines information (2016: 1.200 requests), (2) clinical pharmacy services (2016: 9.000 medication-related problems prevented), (3) pharmacy e-consults, and (4) the drug interactions and pharmacotherapy clinic. While the scope and reach of services was expanded by diversification, the two new services are operated with existing ressources after reassignment of tasks.

What next?

After the implementation of new services (i.e. e-consult, clinic) constant promotion is needed to increase the awareness level among health care professionals in the hospital. Quality assurance and continuity of service provision is crucial for acceptance.

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Author(s)

Chloé HERLEDAN, Laura BEAUMIER, Laurence MINISCHETTI, Marie-Christine ALBERTO-GONDOUIN

Why was it done?

Existing floor stocks are limited to usual psychiatric drugs. On-call resident pharmacists dispense additional treatments during pharmacy closing hours. Hence, extending the floor stocks would facilitate continuity of care. SASC centralisation enables simple and secured access to medication while saving space in care units.

What was done?

A new drug and medical device floor stock was implemented in our psychiatric hospital. The floor stock is contained in a secured automated storage cabinet (SASC) located in a protected area inside the pharmacy and accessible during its closing hours. Utilisation training was offered to nurses through multiple formats.

How was it done?

Floor stock composition has been established from frequent requests made during on-call time and can be consulted on the pharmacy website. Prescriptions and patient informations can be checked before removal on a computer in the SASC area. The SASC requires badge identification, unit and patient name entry and provides traceability of removals. Moreover, cold storage requiring drugs are housed in a refrigerator unlocked through the SASC. Regarding utilisation training, all night nurses had to attend a demonstration of the SASC performed by the resident pharmacists. This demonstration was also offered to day nurses and head nurses during weekly pharmacy open days for three months. In addition, an instruction manual and a video tutorial were produced and uploaded on the website.

What has been achieved?

60/67 (89.5%) night nurses, 80/256 (31.2%) day nurses and 10/20 (50.0%) head nurses have attended the SASC demonstration. A satisfaction survey conducted among trained nurses or head nurses had an 18.7% response rate. 26/28 (92.9%) of respondents attended the demonstration and all were satisfied by its quality. 2/28 (7.1%) only used the instruction manual. All respondents declared being able to use the SASC, however 7/28 (25.0%) would need assistance from the instruction manual or video tutorial.

What next?

Further utilisation training or assistance will be provided by the video tutorial. Removals and prescriptions will be checked by pharmacists to uncover picking errors. Impact on resident pharmacists’ workload will be assessed within six months. Finally, SASC centralised floor stock is an interesting approach for hospital pharmacies with limited staff to improve continuity of care.

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Author(s)

Janne Kutschera Sund, Martin Grotnes, Ingvild Klevan, Lene Lilleaas, Johan Fredrik Skomsvoll

Why was it done?

Lack of comprehensive strategies and funding has made it difficult to develop and implement extensive clinical pharmacy services in our hospital. It has been challenging to secure hospital involvement. A new financial model securing funding from the regional health authority made way for a new joint approach.

What was done?

A dialog based process involving hospital management, clinicians and the pharmacy led to a large increase in clinical pharmacy services in our university hospital.

How was it done?

A literature review was conducted. Based on this, a multidisciplinary project group decided that all clinics and wards were eligible for clinical pharmacy services and should receive extensive information on the topic. As there were limited resources allocated, all clinics were asked to apply for the service. The hospital management received applications three times the number of funded clinical pharmacists.
Prioritizing was based on the following criteria; use of the Integrated Medicines Management (IMM)-method, patient flow, evaluation and research, in- or out –patient clinics, continuation of established services, localization and time schedules on the wards.

What has been achieved?

The long term funding of clinical pharmacy in the health region enabled the hospital pharmacy to recruit and educate highly competent clinical pharmacists.
In less than a year, the number of clinical pharmacists has increased from three to twelve. The number of wards receiving clinical pharmacy services has also grown from three to twelve and there are still plans for further implementation.

The hospital and the ward managements are much more involved in evolving a common patient safety strategy with focus on medication. Specific quality indicators for each patient population and ward are being developed, and clinical pharmacists are now important members of multidisciplinary teams all over the hospital. Pharmacists are integrated in ongoing clinical research projects and publishing.

User surveys show that clinical pharmacy is assessed as a highly beneficial service by both nurses and physicians.

What next?

Develop the IMM-model to include the clinical pharmacists in standard patient care in every clinic and department. We plan to perform follow-up studies on the effects of clinical pharmacy services in different settings.

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Author(s)

Karina Bentzen

Why was it done?

Introducing biosimilar medicines in the clinical setting may significantly reduce hospital medicines expenditure – but only if the biosimilar medicines are used. Lack of knowledge and insecurities about biosimilar medicines among healthcare professionals and patients must to be addressed to ensure implementation in the clinical setting.

What was done?

To facilitate the introduction of biosimilar medicines in Denmark, a special Taskforce was appointed. The aim was to enhance knowledge of biosimilar medicines among healthcare professionals and prepare implementation of biosimilar medicines in the clinical setting.

How was it done?

A special “Taskforce for introduction of biosimilars” was appointed. The Taskforce consisted of physicians including clinical pharmacologists, pharmacists, drug tender specialists and staff from the “Council for the Use of Expensive Hospital Drugs”, who issue national treatment guidelines.
Planning the introduction of biosimilar infliximab in Denmark started more than a year prior to the granting of marketing authorization. During this time, the Taskforce arranged seminars and facilitated meetings with specialists from the clinical setting to provide knowledge of biosimilars, to discuss the introduction of biosimilar medicines and how to switch patients. Based on these discussions the “Council for the Use of Expensive Hospital Drugs” dictated the use of biosimilar medicines nationally.
The Taskforce also created educational materials for doctors, nurses and patients and a “Q & A” website.

What has been achieved?

Biosimilars were adopted into the Danish market after a very quick introduction. The market share of the biosimilars was 95% within 3-4 months.

The price reduction after introducing biosimilar medicines was approx. 60%, and the quick implementation of the drugs in the clinical setting has significantly reduced medical costs.
Total annual savings in Denmark: 22 mio € (infliximab) and 15 mio €* (etanercept. * Estimate based on the first 6 months).

What next?

More new biosimilar medicines are expected to be introduced into the Danish market in the near future. The Taskforce will continue their work to ensure similar successful implementations.

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Author(s)

K. Teimori, H. Colldén, R. Asadian Falahieh

Why was it done?

Therapy at an intensive care unit (ICU) involves co-infusion of multiple drugs into the same IV line. This may involve mixing of incompatible drugs resulting in particulates being infused, putting the patient at risk. In 2012, a local survey showed 65% (n=142) of participating nurses had co-administered drugs where they were unsure of their compatibility. Preventing incompatibilities by providing healthcare practitioners with point of care IV drug compatibility information fitted to local needs was deemed a necessity. Drug compatibility requires a thorough understanding of chemistry, and information from published studies must be evaluated and assessed to determine applicability to local clinical conditions. Clinics had requested the support of pharmacists for this work.

What was done?

An online intravenous (IV) compatibility database based on these data was created. A group of international clinical pharmacists interested in collaborating in improving the quality of the database was identified. Information material aimed at educating healthcare personal was developed.

How was it done?

Published drug compatibility data and information on physiochemical properties were collected and assessed by a team of hospital pharmacists for applicability to seven clinics. Support, guidance and expertise in the subject had been readily offered to clinical practitioners through telephone calls, email and meetings.

What has been achieved?

Six custom compatibility charts totaling 3600 drug pairs have been created, and procedure documents for IV compatibility have been implemented in each clinic. Over 30 educational lectures on IV compatibility have been held.

The database consisting of 2500 drug combinations presents accessible detailed information on compatibility. Its quality is continuously reviewed by international colleagues.

What next?

The database is fitted to national clinical traditions, providing accessible data to nurses and physicians to support decisions on which drugs to co-infuse. In the next few years, the database will become nationally available. If integrated into the electronic journal system, this could help doctors consider compatibility issues while prescribing, further improving patient safety.

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Author(s)

S. Jornet Montaña, M. Martín Marqués, P. Jolonch Santasusagna, M. Juan Aguilar, C. Gomez Blanco, P. Salvador Collado

Why was it done?

The constant development of new therapies against hepatitis C and the lack of experience in their management requires health professionals to work together.

What was done?

An online platform was created to make inquiries, resolve doubts and establish a shared database among clinical pharmaceutics within the province.

How was it done?

Meetings of the provincial pharmaceutical association were conducted to jointly identify shared necessities across professionals and to determine the best communication system to be used in terms of efficiency, speed and reliability.

What has been achieved?

The pharmaceutical association created an interactive platform, which was easily accessible from a virtual campus. The platform eases the tasks of sending inquiries and comments about side effects to all pharmaceutical professionals in the system, simultaneously and in a timely fashion. This platform also allows the creation of debate forums to answer questions, and promotes knowledge sharing among participants. As time goes by and based on experience of new drugs, a drug interactions database is created. The platform also allows knowledge of whether specific combinations of drugs have been used and the hospital’s own experience, even if no official studies exist. In addition, the platform allows updating the previously introduced interactions and shows who has done it, so this participant can be asked if necessary. This system also allows the sharing of written information, such as patient brochures, recommendations, bibliography and scientific society links and other websites of interest.

What next?

The created platform meets the pharmaceutical participants’ expectations and allows equal treatment of all patients independently of the hospital where they are located. This platform allows professionals to work together for the same cause and overcome individual knowledge and resources constraints. This platform will be used for other illnesses for which special pharmaceutical attention is required. Finally, the platform will be expanded by inviting other provinces to join our project.