OPTIMISING CUSTOM PACKS: A STEP TOWARDS A SUSTAINABLE HOSPITAL?
Pdf
European Statement
Selection, Procurement and Distribution
Author(s)
A. KANDEL (1), L. CABRIT (1), C. HUMARAUT (1), A. MASSRI (2), C. TAILHADES (1), S. ARRAKI ZAVA (1), V. GRENOUILLEAU (1)
(1) Pharmacy Department, Medical Devices Unit, Pau Hospital Center, France
(2) Intensive care unit, Pau Hospital Center, France
Why was it done?
Medical devices (MDs) and drugs account for 55% of the carbon footprint of a hospital’s French healthcare system, making this sector a key focus for the ecological transition. The MD sector alone is responsible for 32% of our hospital’s CO2 emissions, underlining the need to rethink our practices in order to reduce our environmental impact.
What was done?
Elimination of waste produced unnecessarily by optimising customised packs (CP) containing the MD required for treatment.
How was it done?
After a multidisciplinary team (pharmacists, intensive care units, anaesthetists, nurses) was put together, packs containing unused medical devices (UMD) were identified in 2 pilot departments: anaesthesia and intensive care. The packs were weighed with and without the UMD. The savings in terms of waste weight and carbon footprint were calculated according to the type of waste: general waste or biohazardous waste. In conjunction with the medical teams and suppliers, the re-evaluation of the MD required and the withdrawal of UMDs led to the updating of CP in the pilot departments.
What has been achieved?
The packs identified include: the suture pack (SP), the central venous line pack (CVL) and the epidural pack (EP). Over one year, the weight of waste avoided was: 64 kg for the SP, 87 kg for the CVL pack, 55 kg for the EP. After modifying these packs, annual CO2 emissions were reduced by 55% for the SP, 14% for the CVL pack and 8% for the EP, with a total annual saving of €5,423. The annual weight of waste was reduced by 206 kg, a saving of 92 kg of CO2: the equivalent of 86 Paris-London train journeys.
What next?
The re-evaluation of CP can generate a significant ecological impact. This initiative is intended to be rolled out on an institutional scale, with the active collaboration of the sustainable development department, and as part of future calls for tender. These adjustments save time for care staff, significantly reduce the carbon footprint, and contribute to the ecological transition. It is essential to strike a balance between economic and environmental imperatives, given the financial constraints facing public hospitals.
BRAIN DEATH: RADIOCHEMICAL PURITY OF THE RADIOPHARMACEUTICAL 99mTc-HMPAO STABILIZED WITH COBALT
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Diana Monteiro
Luísa Álvares
Sara Brandão Madureira
Patrocínia Rocha
Why was it done?
The confirmation of a clinical diagnosis of brain death requires the demonstration of the cessation of brainstem functions and their irreversibility. Therefore, when this evaluation is incomplete or unreliable, it is necessary to support this diagnosis using diagnostic tests such as brain perfusion SPECT. This is performed after the injection of the radiopharmaceutical technetium-99m hexamethylpropyleneamine oxime (99mTc-HMPAO) and by assessing the obtained images for the lack of cerebral perfusion to confirm the diagnosis.
Given the importance of reliable results, a high radiochemical purity of 99mTc-HMPAO is imperative in quality control to prevent false positives.
What was done?
Selection of a method to evaluate the radiochemical purity of 99mTc-HMPAO.
How was it done?
A literature review was conducted to select the most suitable method for the conditions existing in the institution. The research focused on the Summary of Product Characteristics (SmPC), the European Pharmacopoeia (Ph. Eur. 11.0), the United States Pharmacopeia (USP 42) and several published articles.
After selecting the method, three assays were performed to validate it.
What has been achieved?
For evaluating the radiochemical purity of 99mTc-HMPAO, both the SmPC and Ph.Eur. 11.0 recommend a combination of two thin-layer chromatography (TLC) methods with a high-dimension stationary phase, for which the institution does not have a chromatographic tank.
The USP 42 describes a combination of three TLC methods, using acetonitrile as the mobile phase, which is also unavailable at the institution.
In contrast, the miniaturized method by Fuente et al. uses two TLC methods, with a silica gel stationary phase and sodium chloride (0.9%) and methyl ethyl ketone as mobile phases. This method was selected given that the institution has the required phases, the stationary phase dimensions are suitable for the available chromatography tanks and the execution time for the assay is feasible.
For method validation, three assays were conducted, yielding values exceeding 80% (the reference value).
The selected method represents a rapid, reproducible and reliable alternative for evaluating the radiochemical purity of 99mTc-HMPAO. It was implemented in the institution in October 2022.
What next?
In the future, we aim to develop quality control methods for all radiopharmaceuticals in use at the institution, in order to guaranty the quality of all the exams performed.
Hospital pharmacists’ professional empowerment through skills integration: experience of international cooperation between Italy and Tanzania
Pdf
European Statement
Education and Research
Author(s)
Agnese Bosio, Chiara Carcieri, Sixberth Bugeraha, Silvia Scalpello, Giovanna Fazzina, Maria Carmen Azzolina, Gianluca Miglio, Annalisa Gasco
Why was it done?
Drug dispensing and patient monitoring are institutional activities of hospital pharmacists worldwide. Nevertheless, the enhancement of managerial capabilities, hard and soft skills is crucial to tackle the critical challenge arising from geographical, epidemiological, demographic, cultural and legislative differences between different countries.
What was done?
An initiative for cooperation and interaction between hospital pharmacists from different income countries has been developed.
How was it done?
The initiative was led by a pharmacist from an Italian hospital who was hosted by a hospital in southern Tanzania and spent a month collaborating with local hospital pharmacists, in order to streamline integrated workflows and optimise clinical care outcomes and professional training.
What has been achieved?
A Strengths Weaknesses Opportunities Threats (SWOT) matrix was developed to assess the impact on three main areas: drug management, clinical pharmacy and pharmaceutical care.
Strengths: attitude for workflow standardisation, multidisciplinary and multicultural teamwork, sharing of expertise and best practice, speed up of limiting processes in order to develop activities in support of patients and clinicians, time and effectiveness in qualified staff training.
Weaknesses: complexity of procedures for drug import, hospital staff shortage (both pharmacists and physicians), absence of primary care and hospital-territory continuity of care network, clinical severity of patients admitted to hospital, imbalance between clinical pharmacy/pharmaceutical care in favour of drug management.
Opportunities: professional growth due to new healthcare challenges facing, soft skills improvement (problem solving, versatility, working under stress, teamwork, integration, overcoming prejudices), hard skills enhancement (logistics, international legislation, scientific English), budget optimisation for new investments (equipment/staff), improvement of patient safety and overall level of care.
Threats: language/cultural barriers, variable learning curve and resistance to change, barriers in social/professional relationships, individual variability in adaptation period, different patient perceptions of health and medical care.
What next?
Professional integration of hospital pharmacists from different educational and cultural backgrounds could enhance their ability to address different clinical, environmental and socio-economic issues, with the following outcomes: strengthening the professional pathway; optimising outcomes with consequent cost savings; improving the quality of healthcare for patients.
Assesing cold chain compliance for biotherapy drugs in a university hospital’s medical departments
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
AMINE BAYEN, OUMAIMA KHARKHACH, HICHAM EL HORR, LHOUSSAIN ZARAYBY, SANAE DERFOUFI
Why was it done?
It has been observed that within the gastroenterology, neurology, internal medicine, rheumatology, and dermatology departments, there exist inconsistencies and disparities. These include extended transportation times averaging 8 minutes, a lack of isothermal bags for transportation, and refrigerators not connected to the main hospital generator.
Strict adherence to storage guidelines is crucial, as any breach in the cold chain could compromise the drug’s therapeutic effectiveness, increase the risk of adverse effects, and lead to significant financial losses for healthcare institutions.
What was done?
Ensuring optimal storage and transportation conditions for biotherapy drugs in various medical departments within a university hospital by assessing and improving cold chain compliance.
How was it done?
Implemented corrective actions and recommendations have been primarily directed towards minimizing transportation duration and procuring thermal bags for all departments handling biotherapy products. These initiatives encompass enhancing staff awareness in the cold chain process through sensitization campaigns and regularly evaluating refrigerator temperatures. Moreover, a strategic plan is underway to establish their connectivity to the generator system in the near term.
What has been achieved?
A notable reduction in the transportation time of biotherapeutic drugs has been achieved, decreasing the average duration from 8 minutes to 6 minutes. Additionally, the widespread adoption of thermal bags across audited departments has substantially bolstered the stability of biotherapeutic drugs, mitigating temperature fluctuations and enhancing patient safety. Moreover, our efforts in sensitising medical and pharmaceutical staff within these departments have yielded a significant increase in awareness and adherence to stringent cold chain protocols.
What next?
The inconsistencies and disparities identified during the assessment of the biotherapy drug cold chain within our hospital suggest a potential lack of adherence to procedural standards. This situation poses a considerable risk to patient safety, warranting further investigation and action.
Our focus will extend beyond the cold chain assessment to evaluate other pharmaceutical procedures. Specifically, we will investigate the adherence to autoclave sterility cycles for medical devices and the robustness of the preparation process for oncology medicines.
Rethinking pharmacy and therapeutics committee procedures to achieve the efficiency required to overcome hospital complexity
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Sara Rodrigues, Sofia Pinheiro, Vandewalle Björn, Paulo Martins, Sofia Ferreira, Paulo Pereria, Jorge Félix
Why was it done?
Shared decision-making between pharmacists and physicians is key to PTC functioning and efficiency. Responsibilities include managing policies and procedures for appropriate use of high quality and cost-effective health technologies at hospitals. PTC performance is paramount to overall hospital efficiency.
What was done?
This project seeks to assess and redesign (optimize) existing Pharmacy and Therapeutics Committees (PTC) procedures within a University Hospital Centre (UHC – six public hospitals). The goal is to enable sound decision-making that significantly contributes to UHC key performance indicators, all while ensuring timely patient access to effective medication.
How was it done?
The project comprises four phases: (1) gathering feedback from stakeholders (PTC members; hospital service/pharmaceutical department directors) regarding their current involvement in PTC information flows, procedures, and decision-making; (2) developing a value-based criteria-matrix, across stakeholders, in a multiple-criteria decision analysis context, to guide future PTC decision-making; (3) rethinking PTC procedures and information flows; (4) assessing the effectiveness of the redesigned PTC model after 12 months. First phase included: a Likert-scale based survey1 for PTC members to evaluate their involvement in activities described in the internal PTC regulation, and a semi-structured interview-based survey2 for all stakeholders to characterize existing information flows and PTC mediated decision-making processes.
What has been achieved?
First phase: eight of 10 PTC members participated in survey1. Activities with 100% engagement of PTC members: prescription reviews; coordination with National PTC; monitoring of medicine utilization, antibiotics resistance and safety; advise the UHC management board. Activities with major non-engagement: monitoring/reporting of complementary diagnostics prescription (87.5%); medication therapy management programs (62.5%); National pharmacovigilance system activities (62.5%); therapy cost assessment (50%). In survey2 (n=14) authorization process for medicines utilization was accurately characterized, clearly identifying responsibilities for all clinical and pharmaceutical departments. Heterogeneity exists between urgent and non-urgent utilization requests. PTC members and pharmacy departments were more likely to use electronic platforms than clinical departments.
What next?
Next phases are under way to better support current competencies, information flows, procedures, and the shared decision-making processes offering an opportunity to rethink the PTC procedures in the University Hospital Centre and leverage efficiency over hospital complexity.
Using virtual reality to introduce newly hired nurses
Pdf
European Statement
Education and Research
Author(s)
Stine Hygum Sørensen, Henrik Nielsen, Ulla Kloster, Anne Grethe Nørgaard Kyndi, Maja Vad Mortensen, Dorthe Ludvigsen
Why was it done?
The concept of medicine at Gødstrup Hospital is based on Patient involvement in the medicine process. Consequently, the patients bring their own medicine, which is stored in the patient’s room, and additional medicine is supplied in original packages. Medicine dispensing is performed in the patient’s room to allow patient participation. The medicine rooms at the hospital are quite small, because the majority of the medicine is with the patient, but it also makes medicine rooms unsuited for on-site training of new nurses.
What was done?
Virtual Reality (VR) technology was applied for introduction of newly hired nurses to medicine rooms at the hospital.
Newly hired nurses are given a four hour introduction to the concept of medicine at Gødstrup Hospital, Denmark. The introduction is given by an interdisciplinary team of a clinical pharmacist, a pharmacologist and an experienced nurse. The introduction is given in collaboration with the Centre for Research and Education (NIDO) once a month. This ensures that newly hired nurses are given the same, relevant introduction when needed.
Introduction to medicine rooms is part of the training for nurses in introductory positons. Using VR newly hired nurses are given a different and exciting introduction to medicine rooms.
How was it done?
In collaboration with the simulation unit at NIDO we made a VR-video to enable up to 20 new nurses to see the same introduction at the same time. Hospital Pharmacy staff is featured in the VR recording and guides viewers to specific parts of the medicine room, explaining important topics such as waste disposal, hygiene and anatomical therapeutic chemical (ATC) groups.
What has been achieved?
The participants are positive and give the following feedback to the VR segment of the introduction: “It was significantly easier to deal with as a newbie”. “It was very visual as being there in reality”. “There was time to learn in a calm environment”, “It worked fine as a lesson” and “It is a good change from backboard teaching.”
What next?
The monthly introductions continues and further collaboration with NIDO will result in lessons with topics such as pharmaceutical formulations and drug calculations. Perhaps VR will be included in this too.
Clinical radiopharmacy: implementation of pharmaceutical interviews for patients treated by radioligand therapy
European Statement
Clinical Pharmacy Services
Author(s)
Nina RANJIT, Matthieu GALLET, Anthony TRIPLET, Myriam QUERMONNE , Alexandre COCHET
Why was it done?
The rise of RLT is seeing the emergence of new treatments, using radioisotopes such as 177Lu or 223Ra. The radioactive nature of these treatments raises questions from patients. The aim of pharmaceutical consultations (PCs) is to respond to them by providing appropriate information on treatment modalities, adverse effects (AEs) and radiation protection rules. Thus, we carry out a PC at the initiation of an RIV for all new patients from January 2022 for PLUVICTO.
What was done?
Radioligand therapy (RLT) consists of the administration of a radioactive drug. It makes it possible to treat cancer patients by specifically targeting tumour cells and destroying them using ionising radiation.
These particular treatments raise questions from patients. This is why we have implemented pharmaceutical interviews since 2022 and the beginning of RLT by PLUVICTO® during the first treatment, for all patients concerned. Subsequently, these consultations were extended to other therapies (lutathera, xofigo).
How was it done?
Before initiating RLT to a new patient, radiopharmacists check the eligibility of patients and the conformity of the indication. A few days before the first treatment, the patient’s file is consulted and important information is noted (urinary or fecal incontinence, digestive problems, biological assessment, co-medications). The day of the treatment, a personalized care plan is drawn up by the radiopharmacist and an information sheet bringing together information on the treatment (interval of treatments, dose, etc.), side effects and their management and the rules of radiation protection are provided. to the patient.
What has been achieved?
Collaboration with nuclear doctors has been set up to optimise patient care and information.
When necessary, pharmaceutical interventions are formulated directly to the clinician and plotted in a table.
Facing the success of these PCs we implement them for lutathera and xofigo, the two other RLT available.
In case of side effects, we also declare it to the pharmacovigilance service and give advice to patients and/or clinicians for manage them.
All documents are recorded in the computerised patient file.
What next?
The next step is to evaluate patient’s comprehension before the first interview to adapt its content to the patient.
We also would like to evaluate the patient’s satisfaction and expectations.
Discussions are underway to financially promote these tripartite consultations as exists for oral chemotherapy consultations.
A new medication-use process implemented in the perioperative setting
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Almudena Ribed, Alvaro Gimenez-Manzorro, Beatriz Torroba-Sanz, Ana De Lorenzo-Pinto, Maite Portas-Gonzalez, Maria Dolores Ginel-Feito, Pilar Cabrerizo-Torrente, Maria Luisa Martin-Barbero, Ana Herranz-Alonso, Javier Hortal-Iglesias, María Sanjurjo-Saez
Why was it done?
There is a high prevalence of medication errors in the perioperative setting. Health organizations highlight the need for effective practices to ensure safe medication use. A group of pharmacists, surgeons, anaesthesiologists, nurses, and IT technicians coordinated by the management was formed in 2020. Failure mode and effects analysis (FMEA) of the perioperative use of drugs was performed in 2021. The group detected up to 25 failure modes and conducted a bibliographic review to gather and prioritise the implementation of safety practices.
What was done?
We re-engineered the process of medication use in the perioperative setting, from pre-admission to discharge, and implemented safety practices to improve safe medication use in the daily practice.
How was it done?
Obstacles were overcome as a result of the multidisciplinary teamwork, management support and the safety culture existing in our hospital. In addition, we listened to health professionals’ opinions, provided monthly information sessions in the Anaesthesia and Pharmacist Department in 2022 and disseminated information through the hospital website.
What has been achieved?
Eight safety practices were implemented in daily practice:
1.Eight safety practices were implemented in daily practice:
1. Implementation of automated dispensing cabinets.
2. Identification and recommendations for high risk drugs.
3. Standardisation of anaesthesia and difficult airway trolleys.
4. Preparation of general anaesthesia trays with ready to administer drugs.
5. Design, development, and implementation of a one-step computerised provider order entry (CPOE) in the operating room, with bar code administration technology.
6. Implementation of a pharmaceutical care programme for surgical patients based on medication reconciliation in all transitions of care.
7. Implementation of new alerts in the clinical decision support system linked to the CPOE to improve pain, anticoagulation, and antibiotic management in the surgical patient during follow-up.
8. Development of new protocols for perioperative management of chronic medications, anticoagulation, diabetes, and antibiotic prophylaxis in the surgical setting.
What next?
The new medication-use process describes a practical and real approach to promote perioperative patient safety in the daily practice. Transfer into other centres is achievable by motivating healthcare professionals, engaging in safety culture and creating multidisciplinary alliances. There is a need to assess the impact and evaluate these safety practices to ensure ongoing improvement.
Novel specialist uveitis pharmacist role in the uveitis multidisciplinary team (MDT) and evaluation of new dedicated patient email helpline
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Ann-Marie Goacher
Why was it done?
To add expert pharmacy skills to the uveitis MDT. Provide pharmacist led improved education, compliance, monitoring, follow up and access via helpline for uveitis patients on immunosuppression.
What was done?
Expansion of the uveitis (MDT) service to include a specialist pharmacist
How was it done?
COVID allowed us to pilot an innovative service enhancing uveitis patient care. An MDT was established consisting of a specialist consultant, two specialist doctors, optometrist and expert pharmacist in ophthalmology (EPO). The EPO supports weekly MDT sessions through establishing a patient helpline, standardised recorded counselling and on-going follow up of pharmaceutical needs of new and established patients. The main challenge was to obtain funding to maintain this service post COVID. Clinic space remains a challenge due to the limits imposed by the availability of rooms.
What has been achieved?
This innovative pharmacy service provides a blueprint for other specialities to incorporate expert pharmacy skills into the direct care of outpatients. Integration of the EPO into the uveitis MDT benefits clinicians by redirecting prescribing workload, reducing patient enquiries, improvements in clinic flow by moving patient counselling to the EPO and patient safety through instant access to pharmaceutical specialist knowledge. Initial informal MDT feedback has been positive.
Patients profit from access to EPO via the patient helpline. Analysis of 900 emails received over a 2-year period showed the main reasons patients contacted us were for enquires related to blood tests, medication supply, appointments, side effects, worsening symptoms and confirming instructions regarding medication. Feedback from a patient satisfaction survey overall was positive. Patients were asked to rate the service between 1 (poor) and 5 (excellent), with 31 patients responding. The results show access to the team was rated 4.6/5, satisfaction with the speed of the response was 4.29/5 and the quality of response was rated 4.48/5.
What next?
Improved IT databases is something for review, the main barrier being funding. This would make recording and auditing of patient interactions and data more robust. In the future I would like to see national guidance that recommends pharmacists as part of the uveitis MDT as standard.
The role of hospital pharmacists in gene therapy preparation
Pdf
European Statement
Production and Compounding
Author(s)
Lucija Tominović Gjivić, Gabrijela Kos, Anita Šimić
Why was it done?
In order to ensure correct use of voretigene neparvovec and minimise the risks associated with its administration, the product can be distributed only through treatment centres where qualified staff (vitreoretinal surgeons and pharmacists) have participated in the mandatory risk management plan (RMP) education program required by EMA.
Since voretigene neparvovec has to be transported and stored frozen at ≤-65 ºC, has short shelf life after dilution (4 hours), contains genetically modified organisms and must be handled according to local biosafety guidelines, there was a need for establishing standard operating procedures (SOPs) for each step of the treatment process.
What was done?
The University Eye Clinic, University Hospital Sveti Duh in Zagreb, Croatia, was designated as the world’s 6th gene therapy centre in 2020.
Hospital pharmacists, as part of a multidisciplinary team, play an important role in preparation and administration of the gene therapy product voretigene neparvovec which is indicated for the treatment of patients with vision loss due to inherited retinal dystrophy caused by biallelic RPE65 (retinal pigment epithelium-specific 65 kilodalton protein) mutations.
How was it done?
The multidisciplinary team consists of a paediatric ophthalmologist, an inherited retinal disease specialist, retinal surgeons, pharmacists and nurses.
SOPs were created for: ordering process, storage of the product, coordination between members of the multidisciplinary team, preparation of the product, administration and disposal of waste.
Preparation of voretigene neparvovec is performed under aseptic conditions in a Class II vertical laminar flow biological safety cabinet (BSC) according to Pharmacy Manual which was ensured by the manufacturer.
What has been achieved?
Since 2020. there had been 47 dose applications of voretigene neparvovec (26 patients, Croatian and nonCroatian citizens).
The prevalence of inherited retinal dystrophy associated with biallelic RPE65 mutation is 1:200 000 and it is expected that there are 19 individuals (population of 3,8, million) with biallelic RPE65 mutation in Croatia, and 13 of them were detected since 2020.
There were no registered side effects which could be associated with errors during the preparation or administration of voretigene neparvovec.
What next?
With the increasing number of gene and cell-based therapies, the need for continuous education of hospital pharmacists and exchange their experiences is greater than ever.