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Author(s)

Alba María Fernández Varela, María Isaura Pedreira Vázquez, Sandra Koprivnik, Ana María Montero Hernández, Isaura Rodríguez Penín

Why was it done?

Therapeutic drug monitoring (TDM) allows an optimised pharmacological treatment and increases safety. Lately, we detected low interest in TDM which was confirmed from our annual activity report. An observational prospective study was carried out in a second- level hospital attending an area of 175 930 patients. The study included all inpatients prescribed a drug eligible for TDM from November 2020 to January 2021. The aim was to improve treatment individualisation of hospitalised patients through an active proposal for drug level determination of drugs susceptible for TDM at our institution: digoxin, vancomycin, antiepileptic drugs (carbamazepine, phenytoin, phenobarbital and valproic acid).

What was done?

The pharmacist encouraged therapeutic drug monitoring of susceptible treatments by an active proposal for drug level determination in the prescriptions programme.

How was it done?

Daily, a list of eligible patients was obtained. To this end, a filtering software was used. Taking into account patient’s demographics, clinical and analytical variables (creatinine clearance, the last TDM result, diagnosis) and active prescriptions (treatment initiation, interactions), the pharmacist makes a recommendation for plasma drug level determination.
Data sources: electronic prescription program, pharmacokinetic validation program and electronic medical record.

What has been achieved?

119 proposals of TDM were made in 107 patients: 79 digoxin, 31 vancomycin, 4 valproic acid, 3 carbamazepine and 2 phenytoin. 45,8% women.
74 drugs were discontinued before possible sample extraction and 5 monitorisations could not be performed due to patient death. Of the 40 remaining proposals, the physician requested monitoring of 35 drugs, which meant 87,5% acceptance rate.
It was observed that 17 levels were low or at a lower limit (a dose increase with subsequent verification of levels was proposed in 8 cases and accepted in all of them), 13 levels were in range, 4 were high or at an upper limit (in 3 of them the dose was decreased). One sample was extracted after the drug administration (vancomycin) therefore without value.

What next?

Pharmacists can contribute to treatment optimisation by being proactive. Many resources are not needed unless the burden of care was a limiting factor. The education and promotion of TDM would be interesting to improve the use of this service.

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Author(s)

Carlos Santos Rodríguez, Silvia Irene Corrales Vargas, Maria de los Ángeles Peña Peloche, Alfredo Julian Jover Sáenz, Miguel Ángel Ramos Gil, Arturo Morales Portillo, Marta Mir Cros, Francisco Ignacio Torres Bondia, Lluis Marqués Amat, Joan Antoni Schoenenberger Arnaiz

Why was it done?

Beta-lactam antibiotics are the most commonly used group of antimicrobial drugs but are also the ones with the most significant induction of allergic reactions. However, it is known that many of these patients do not present reactions upon rechallenge or have false allergy warnings in the medical records.

What was done?

To assess the impact of a pharmacist-driven programme for active beta-lactam allergy warning removal in adults in collaboration with the Allergology service.

How was it done?

We identified adults with active beta-lactam allergy warnings among outpatients aged 35 to 45 years over 26 months.
Both in the hospital and primary care setting the pharmacist assessed the current information of the cases in the electronic medical records (EMR) and through personal interviews or by telephone. The following data were retrieved: year of allergy registration, type of reaction described, tolerance of beta-lactam antibiotics, and the existence of Allergology reports.
The pharmacist, previously trained by the Allergology service, could proceed to remove or confirm the allergy label, if applicable, or refer the patient to the Allergology service for allergy tests.

What has been achieved?

We reviewed a total of 1178 cases with active beta-lactam allergy warnings. The most frequently implicated beta-lactam drug was amoxicillin, with 170/1178 (14.4%) cases.
111/1178 (9.4%) of cases had an allergic reaction in childhood, and in 714/1178 cases (60.6%) EMR did not describe the symptomatology or treatment that justifies the allergy.
The allergy warning was directly removed in 93/1178 (7.9%) of patients, as they had previous reports of Allergology, had tolerated antibiotics after the allergic reaction, or did not present symptoms compatible with an allergic reaction.
The review confirmed allergic warnings in 43/1178 (3.65%) cases, according to the symptomatology and the information recorded in the Allergology reports.
One thousand and forty-two cases were referred for beta-lactam allergy test performance in the allergology service, of which 47% yielded a negative result.

What next?

The pharmacist is qualified to remove the warning in cases with a doubtful allergy to beta-lactam antibiotics after a thorough medical record review and informed consent. Moreover, the pharmacist can provide valuable information that allows the classification of warnings according to the detected risk and facilitates subsequent decision-making by the allergist.

Author(s)

Baptiste Fulbert, Florian Poncelet, Marilyne Legrand, Céline Mongaret, Dominique Hettler

Why was it done?

Very frail elderly patients are a particularly high-risk population due to their frequent multi-medication and the risk of associated adverse effects.
Clinical hospital pharmacists play an increasingly important role in patient care.

What was done?

We developed a program comprising several clinical pharmacy services for very frail elderly hospitalization.

How was it done?

We conducted a 3 month prospective study in short and middle geriatric stay included patients admitted in emergency department aged at least 75 with a Short Emergency Geriatric Assessment (SEGA) frailty score above 11. We performed, as clinical pharmacy services, best possible medication history (BPMH) in the emergency department and medication reconciliation at admission (MRA) in hospital ward and medication review during hospitalization. Medication reconciliation at discharge (MRD) was carried out on a geriatric medicine unit over 2 months. All activities were performed by pharmacy students, two residents and a pharmacist.

What has been achieved?

120 patients were included. 96 BPMHs were performed : 62 in emergency department and 34 in hospital ward.
MRA was performed for 81 patients (68%), identifying 774 discrepancies of which 19 (3%) were unintentional discrepancies (UD), 6 (32%) involving Digestive Tract and Metabolism drugs. 9 (47%) of these UDs concerned omissions.
During the 163 medication reviews, pharmacist performed 98 pharmaceutical interventions (PIs) for 53 patients, with an acceptance rate of 56%. Most of drugs involved with the acceptance rate was Nervous System drugs (20;36%) and Digestive Tract and Metabolism drugs (16;29%). Among the accepted PIs, 22 (40%) relate to dosage adjustment.
Finally, MRD was performed for 25 (21%) of patients identifying 256 discrepancies, 8 of which (3%) were UDs, mainly involving Digestive Tract and Metabolism drugs (5;63%). 5 (63%) of these UDs concern omissions.

What next?

The high number and nature of the discrepancies support the idea that this population is a relevant target for a clinical pharmacy program.
This program could be applied in other hospitals with the hospital pharmacists and provide a better care for these patients.
The development of MRD in geriatric wards and collaboration between hospital pharmacists and primary care professionnals, by a discharge summary to handover the changes between the entry and the exit prescription can complete this study.

Author(s)

ANA CASTRO BALADO, MARÍA TERESA RODRÍGUEZ JATO, IRIA VARELA REY, MANUEL BUSTO IGLESIAS, FRANCISCO CAJADE PASCUAL, MARIA PUENTE IGLESIAS, IRENE ZARRA FERRO

Why was it done?

The prevalence of obesity has increased considerably in last decades. Pathophysiological changes in obese patients (body mass index >30kg/m2) produce pharmacokinetic and pharmacodynamic alterations that can condition the correct exposure to drugs if standard dosages are used. Incorrect dosing in obese patients can lead to toxicity or therapeutic failure. Usually, it is difficult to find information on drug dosing in this population, being sometimes contradictory.

What was done?

To develop an antimicrobial dosage infographic guide for obese patients to facilitate the correct prescription and validation in our hospital.

How was it done?

Initially, the pharmacy service established the antimicrobial groups to be included in the infographic guide, and within each of them, the most used in hospitalized patients were identified. A bibliographic search was carried out using the keywords “obese”, “dosing”, “antimicrobial” and “patient”. Technical data sheets, PubMed, Google Scholar, UpToDate, Micromedex and other hospital guidelines were consulted. A peer review was carried out and a table with antimicrobial groups and subgroups was designed, stablishing the body weight recommended for the adjustment if needed (total weight (TBW), ideal weight (IBW) and adjusted weight (ABW)), doses, and observations (monitoring of plasma levels, administration in extended/continuous infusion and/or special considerations). The table consisted of a total of 38 antibiotics, 10 antifungals, 6 antivirals and 4 antituberculous drugs. Of the total antimicrobials reviewed, 40% were dosed in obese patients by maximum dose, 38% were dosed based on weight (21% by ABW, 10% by IBW, and 7% by TBW) and 22% by standard doses. Equations for body weight descriptors were added in the infographic.

What has been achieved?

The protocol was validated by the hospital’s infectious diseases commission. Dosing information was then entered into the hospital’s electronic prescribing program facilitating the correct antimicrobial prescription and validation in obese patients. Training was provided in the intensive care unit, and the final document was disseminated through the hospital intranet and via email to all prescribing physicians in the center, being well embraced.

What next?

We will continue making formative sessions, as well as possible updates that may be beneficial for a better antimicrobial dosing in obese patients to avoid toxicities and/or therapeutic failure.

Author(s)

Mª Ángeles Parro Martín, Beatriz Montero Llorente, Teresa Gramage Caro, Manuel Vélez Díaz-Pallarés, Miguel Ángel Rodríguez Sagrado, Hilario Martínez Barros, Ana María Álvarez Díaz

Why was it done?

To ensure continuity of treatment and pharmacotherapeutic follow-up in patients vulnerable to SARS-CoV-2 infection included in a home delivery and telepharmacy program.

What was done?

Implementation and adaptation of home delivery and telepharmacy during the first year of the COVID-19 pandemic.

How was it done?

A work procedure was designed to detail the new functions to be performed by administrative assistants (AA), pharmacy technicians (PT) and pharmacists (PH). A first procedure was designed, which was adapted and improved after 6 months of experience, giving rise to procedure 2.

Procedure 1

– AA phone call to patients scheduled to obtain consent for home delivery and confirm delivery data.
– The PH grouped patients who had confirmed home delivery in the appointment manager.
– The PH reviewed the electronic prescription of all patients and performed telepharmacy to those who were due and/or had incidents.
– The PT prepared the packages.

Procedure 2

Phase 1

– The AA called all patients scheduled until the end of the year to offer them the option of remaining in the home delivery and telepharmacy program permanently. If they accepted, their consent and delivery data were recorded. From this point on, the call to offer home delivery and telepharmacy was discontinued; it was only offered to patients when they attended in person.
– A specific diary for home delivery patients was created.
– The telepharmacytelepharmacy was added to the PH diary.

Phase 2

– Trained PT in home delivery incident resolution (address changes, absent patients, package rejection) to reduce FAR’s working hours.

Phase 3

– Development of a computer application: computerization of manual processes (labels, identification of refrigerated shipments, SMS delivery confirmation sent to patients, and request for appointment changes).

What has been achieved?

31,066 home delivery have been performed on 7,170 different patients. 7,443 telepharmacy consultations have been performed.

PT training and computer development has reduced the PH dedication from 7 hours to 3 hours.

What next?

Establish criteria for prioritization of patients who are candidates for home delivery and telepharmacy.
Implementation of video call instead of telepharmacy

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Author(s)

Ignacio Salar Valverde, Maria García Coronel, Consolacion Pastor Mondéjar, Mayte Gil Candel, Iris Muñoz Garcia, Carles Iniesta Navalon, Elena Urbieta Sanz

Why was it done?

This project was carried out to avoid the possibility of contagion by SARS-CoV-2 when going to collect the medication. The circuit began at the end of March and the month of April 2020.

What was done?

Send the hospital dispensing medication to the patient’s home.

How was it done?

The first step was to specify the patient was considered at risk for SARS-CoV-2, in the end, patients over 65 years of age or immunosuppressed were considered at risk.
The second step was what order to follow to select and evaluate candidate patients for home delivery, for which the solution was simple, it was decided to follow the order of the pharmacy agenda for the collection of medication. The SELENE® electronic medical record program was used to evaluate the patient’s risk.
The third step was to contact him by phone, to check if there was a possibility of collecting the medication by a family member / caregiver, and if not, confirm a delivery address.
The last step was the preparation of the medication in the proper conditions of conservation and identified with the name and address of the patient. Shipments were organized from the pharmacy service. Patients were given an appointment in the pharmacy agenda for the next shipment.

What has been achieved?

There were 139 home deliveries of medication, 47 in March and 92 in April. Around 139 telephone calls were made, they are not counted, not all patients could be contacted in the first attempt, and up to three attempts were made per patient.
The majority, 124 shipments, were made through the service that the hospital made available to them, except for 13 that were made through the Red-Cross and 2 through Civil-Protection.

What next?

Although the delivery of medication at home and was already carried out in some pharmacy services, because of the pandemic it has spread to the rest of the hospitals in our country.
This service should be maintained, despite its cost, for patients who meet a series of criteria, which must be established and agreed upon. In addition, a telephone follow-up should be carried out on the patients that we send the medication to their home.

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Author(s)

MARGARITA BELTRAN GARCÍA, NATALIA MARTÍN FERNÁNDEZ, MERCEDES SALGUEIRO LAZO, SANTIAGO SANDOVAL FERNÁNDEZ DEL CASTILLO, MIGUEL ÁNGEL CALLEJA HERNÁNDEZ, ANTONIO LEÓN JUSTEL

Why was it done?

AKI is an underdiagnosed syndrome due to delay in detection and late referral to the nephrology unit. A real-time electronic alert system integrated into a multidisciplinary protocol could be useful for early identification and diagnosis.
Among the risk factors associated with AKI is the use of nephrotoxic drugs such as NSAIDs and COX-2, ACE inhibitors and ARA-II, Cyclosporine and Tacrolimus.

What was done?

A multidisciplinary protocol was established for the detection and early action of prerenal AKI inpatients with hospital and Primary Care monitoring.

How was it done?

An authomatic electronic tool, agreed between Biochemistry and Nefrology units, was designed for the selection of AKI patients. The pharmacist was contacted when a prerenal AKI was detected, who generated an alert in the electronic prescription system in order to recommend actions related to prescribed nephrotoxics drugs. An analysis was request to check renal function in these patients, after 48 hours in the hospital and after 1 month of discharge from the Primary Care.
There were many previous meetings and the leadership of each unit was maintained in the participation of strategies.

What has been achieved?

The aim was to improve the detection of prerenal AKI in inpatients and increase the quality of healthcare in these patients.
For this 3-month pilot phase, were selected 3 clinical unit and 9 prerenal AKI cases have been detected. The most frequent risk factors were: 9 cases due to volume deplection, 6 due to nephrotoxic drugs use and 3 due to chronic kidney damage (CKD). The measures adopted were: add fluid therapy in all cases, cancel nephrotoxic drugs and modify the diuretic drugs prescription in 6 of 7 cases. There was only 1 death.

What next?

This strategy will be extended to all hospital clinical units. Data will be obtained on incidence and morbidity and mortality in these patients, as well as on length of hospital stay.

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Author(s)

Noelia Vicente Oliveros, María Muñoz García, Álvaro Ruigomez Saiz, Montserrat Ferre Masferrer, Teresa Bermejo Vicedo, Eva Delgado Silveira, Lucía Quesada Muñoz, Ana María Alvarez-Diaz

Why was it done?

An analysis of the indicators of the perioperative process reflected the need to improve their quality. One of the causes of scheduled surgery cancellation was the lack of the follow up of the anaesthetist’s medication recommendations. Medications need to be carefully managed to prevent perioperative complications.

What was done?

We designed and implemented a flow chart to ensure the patient compliance of anesthetist’s medication recommendations prior to surgery. We designed a protocol for the perioperative medication management.

How was it done?

A multidisciplinary group was formed with the management of the hospital and representatives of all the services involved in the perioperative process. The group designed the flow chart of the process by consensus. Patients were candidates to enter in this process if they were on treatment with anticoagulant or 2 or more medications from the following groups: antiplatelet, antihypertensives, antidiabetics. A pharmacist called by phone three times (the day before, the day of medication change, and the day after) to the patient to ensure the compliance of anaesthetist recommendations. If there was a lack of compliance, the pharmacist contacted the surgeon who was in charge of deciding if the surgery procedure continued as scheduled. Moreover, the domiciliary medication of these patients were reconcilliated and recorded in their health record. Healthcare professionals could consult it during hospital stay. The group designed a protocol for the perioperative medication management with different medical specialists.

What has been achieved?

The project started in April 2019. The pharmacist called patients with scheduled surgery of lower limbs. A total of 31 patients benefited from the new flow chart. The pharmacist detected 38 medication errors; two involved errors concerning the suspension of anticoagulant drugs prior to surgery and four implied antihypertensive drugs. Once, it was necessary to contact the surgeon. In this case, the surgeon decided to continue with the surgery as schedule. Fifty-seven medications suffered a change in the period between the anaesthestic visit and the surgery, nine of them belonged to the monitored medication group. 

What next?

The next steps are to spread the flow chart to other patients, to distribute the protocol among hospital healthcare professionals and to implement a procedure for the reintroduction of the modified medication.

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Author(s)

Ane Hornbaek Mortensen

Why was it done?

Previously, a quarterly report showing adherence to national treatment guidelines was issued to all hospital administrations in our region. It was their responsibility to forward this to the appropriate specialists/consultants. This often failed and even when it was done, our experience showed that it wasn’t read by the consultants. Consequently, prescription patterns didn’t change despite the report highlighting the wards that weren’t complying with the national treatment guidelines.

What was done?

Short newsletters including graphs/tables showing the ward’s degree of adherence to national treatment guidelines were emailed to the chief consultant of the specific ward.

How was it done?

In our region a 6-person analytical team, which includes 3 hospital pharmacists, monitors adherence to national treatment guidelines issued by our national council for the use of expensive hospital medicines (RADS). Based on the results, the analytical team decides which newsletters to write. The hospital pharmacists in the analytical team are responsible for writing the newsletters and emailing them direct to the relevant specialist/consultant.

What has been achieved?

It seems as if the introduction of more targeted information has led to more rapidly changing prescription patterns. One example is oral iron chelating agents to hematological patients where a RADS guideline was issued recommending that all new patients should receive deferipron instead of deferasirox. This information was initially issued through the usual channels (via hospital administration) but no change in the use of deferipron/deferasirox was seen. This only happened after emailing a newsletter directly to the chief consultants of the three hematology wards in our region, showing the current use of deferipron/deferasirox and the potential cost reduction. Nine months and three newsletters later the percentage of deferipron use on the hematology wards increased from 2% to 27%, leading to a 22% cost reduction. Target was 25% deferipron (the guideline only covered new patients). The total increase in the percentage of deferipron use on hospitals in our region was 351% compared to an increase of between 0 and 19% in the other four national regions.

What next?

Continued and increased use of targeted communication in the health care system is required to ensure that specific information reaches the relevant players.

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Author(s)

Susanna Saano, Tiina Koskinen, Hillevi Rautiainen, Minna Taam-Ukkonen