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TO IMPROVE TIMELY MEDICINES PROVISION AND ENSURE SAFE PRESCRIBING AS WELL AS SUPPORT EARLY DISCHARGE PLANNING TO IMPROVE FLOW INSIDE AND OUTSIDE AN NHS TRUST

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European Statement

Clinical Pharmacy Services

Author(s)

Christina Anastasiadou – Lead Pharmacist Acute & Emergency Medicine
Karen Dicks – Chief Pharmacy Technician Medicines Management
Radhika Patel – Pharmacy Technician MMS

Why was it done?

Until October 2023, the A&E department in Croydon University Hospital in London lacked a full-time pharmacy service, unlike other London trusts. This has contributed to suboptimal medicine management and a delay in the identification of prescribing errors. This has resulted in longer stays, missed medication doses, and a rise in patient safety incidences. At a hospital level this reduces flow and increases cost due to medication wastage. Ultimately, the aim is to improve the flow of patients within the hospital via timely medicines provision, early clinical pharmacy intervention and early discharge planning.

What was done?

We have obtained funding from the Better Care Fund for a period of 2 years. This funding is aimed at assisting local systems in effectively achieving the integration of health and social care in a manner that promotes person-centred care, sustainability, and improved outcomes for individuals and caregivers. Therefore, we introduced a full-time pharmacy service including one pharmacist and two medicines management technicians (MMTs)—one full-time and one part-time. This initiative was implemented as a 2-year trial period, using key performance indicators (KPIs) to evaluate its effectiveness.

How was it done?

Data has been collected against the below KPIS:
1) Number of drug histories completed on admission, before patient is allocated a ward (by MMT or pharmacist) per calendar month.
2) Number of medicines reconciliations completed (by pharmacist) per calendar month.
3) Number of clinical interventions completed by all members of the pharmacy team.
4) Savings secondary to the use of patient’s own drugs (PODs) brought from home for administration to reduce medicines wastage.
5) Savings due to the return of medicines to inpatient pharmacy for re-use from other patients when appropriate.
6) Time between request of medicines from pharmacy dispensary and medicine being dispensed, checked and released to A&E.
7) Review of stock lists in all areas in A&E.
8) Reduction in omitted doses.
9) Discharge medicines supply and screening from A&E to streamline discharge.
10) Number of patients counselled on their medicines and provided with patient-friendly information on them.
11) Number of referrals to community teams i.e allocated chemist via Discharge Medicines Service, Integrated Care Network (ICN) pharmacists or specialty teams (i.e anticoagulation clinic for newly initiated anticoagulant) to provide continuation of care.
12) Liaising with specialty teams within the hospital to expedite review and treatment in a time efficient and cost-effective way.

What has been achieved?

The current pharmacy team is fully integrated into the A&E service and has contributed significantly towards advancing patient experience, via early pharmacy engagement with patients. During the first 10 months of the project, we have data to show:
1) A 540% increase in drug histories and medicines reconciliation on admission.
2) A 19.525% increase in clinical interventions and early detection of medication errors.
3) We have completed 5 teaching sessions so far, in order to tackle common prescribing and medicines management inaccuracies and embedding solutions into nurses and doctors training.
4) We have contributed towards the reduction in omitted doses by 6%.

Positive contribution towards tackling medicines wastage has been shown too. Our team contributed towards saving £13.110 from April to September 2024 by using PODs for administration in hospital and £10.483 by returning dispensed medications to the inpatient pharmacy for recycling and use for other patients for the same time period.

In addition, the team has completed 66 referrals to the community pharmacy team for follow up on newly started medicines, stopped medicines, adherence concerns and polypharmacy. This is in order to provide continuous care and establish follow-up after discharge from hospital.

All in all, improved safe patients flow in and out of hospital.

What next?

Work towards a business case for a permanent pharmacy service in A&E, to continue further developing the above. Utilise all the skills our MMTs hold, in order to continue working on patient safety, improved flow and cost improvement plans. Introduce a pharmacist-prescriber who will be able to tackle arising problems as soon as possible and provide high quality care in liaison with doctors, nurses and advanced care practitioners.

CIRCUIT FOR THE PREPARATION, CONTROL, AND DISPENSATION OF AUTOLOGOUS SERUM EYE DROPS IN A PHARMACY SERVICE

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European Statement

Production and Compounding

Author(s)

Eva Gómez-Costa; María Begoña Feal-Cortizas; María Mateos-Salvador; Sandra Rotea-Salvo; Andrea Luaces-Rodríguez; Laura Caeiro-Martínez; Clara Fernández-Diz; Andrés Torres-Pérez; Luis Margusino-Framiñán; María Isabel Martín-Herranz

Why was it done?

Implement a circuit for the preparation, microbiological control, analytical control of patients, and dispensation of autologous serum eye drops in the Pharmacy Service (PS) of a tertiary-level hospital.

What was done?

Autologous serum eye drops are classified as a special medication that must be prepared in authorized centers with an up-to-date patient registry. This initiative aims to ensure the safe use of autologous serum eye drops, guaranteeing quality and safety in their preparation and administration.

How was it done?

The circuit was established in the PS in 2015. After prescription by the Ophthalmology Service, pharmaceutical validation confirms that the treatment is optimal and complies with regulatory requirements. Blood samples are collected from patients under controlled conditions, and the serum is prepared in a vertical laminar flow hood. Once prepared, the eye drops are stored frozen in the PS until dispensation to the patient. The pharmacist reviews the microbiological control of each batch and the patient’s serological results. When collecting the eye drops, the pharmacist records batch traceability and provides the patient with necessary information on storage and administration.

What has been achieved?

Between January and August 2024, 294 patients were treated, with 477 blood extractions performed and a 11,925 eye drops prepared. Autologous serum concentration: 20%(76.9%), 30%(11.5%), 50%(11.2%), and 100%(0.4%). Microbiological control of the eye drops: 98.1% negative and 1.9% false positives, confirmed by a second negative control. Infectious diseases were detected in the serology of 3 patients: hepatitis C(1), hepatitis B(1) and syphilis(1). These data reflect a high success rate in the preparation and quality control, as well as the effectiveness of the implemented circuit. Additionally, the system has allowed for the early detection of viral infections, reinforcing treatment safety.

What next?

The implementation of this circuit has proven effective in ensuring the safety and efficacy of autologous serum eye drops, providing rigorous control over treatments and the quality of dispensed products. Future steps will involve pharmacists requesting serological tests and developing protocols for managing patients with identified infections. Furthermore, patient surveys will evaluate treatment effectiveness and overall patient experience.

AN APPROACH TO SHIFT FIRST-LINE OPIOID FOR ACUTE PAIN MANAGEMENT IN ORTHOPAEDIC SURGERY TOWARDS MORPHINE

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European Statement

Patient Safety and Quality Assurance

Author(s)

RBH, Rie Bager Hansen (presenting author), rie.bager.hansen@regionh.dk
ALK, Annabel Lee Krarup
The Capital Region Pharmacy, Hvidovre, Denmark and Department of Orthopaedic Surgery, Amager og Hvidovre Hospital, Copenhagen

Why was it done?

Patients undergoing acute orthopaedic surgery experience significant pain. The choice of pain-relieving treatment is based on national guidelines and regulatory actions. Considering the U.S. Opioid Crisis and the risk of opioid addiction, it was in 2022 politically decided by the Capital Region of Denmark to focus on consumption patterns of opioids within the region’s hospitals. Morphine is considered an opioid with a lower risk of misuse and was recommended as the first-line opioid. At the start of 2022, the Department of Orthopaedic Surgery at Hvidovre Hospital accounted for approximately 30% of the total oral opioid consumption with oxycodone being the preferred opioid. Thus, a strategy was initiated to shift opioid use towards morphine.

What was done?

The Department of Orthopaedic Surgery initiated a strategy to shift opioid use in hospitalised patients towards morphine. The strategy included including education, revision of guidelines and technical modifications to promote appropriate prescribing practices.

How was it done?

Opioid consumption was continuously monitored and evaluated. At the same time, administration of the antidote naloxone was recorded. The initiative included 1) education about the risk of opioid misuse, 2) e-mail follow-up to clinicians reinforcing that morphine was the first-line opioid, 3) revision of pre-filled electronic prescription packages used at the ward and operating room, 4) publication and implementation of a regional guideline specifically aimed at acute pain management in the orthopaedic surgery setting, and 5) ongoing support from pharmacists to facilitate appropriate selection of opioids.

What has been achieved?

Opioid consumption effectively shifted towards morphine, with the proportion of patients receiving oral morphine increasing from about 40% to approximately 80% of patients administered oral opioids. Moreover, the shift has remained stable for the past 10 months following the last intervention and there has been no trend toward increased usage of naloxone.

What next?

Future efforts will aim to identify reasons behind patients being prescribed non-morphine opioids and to investigate the specific circumstances under which naloxone is administered. This will enable further refinement of opioid prescribing practices and enhance patient safety.

SEMI-AUTOMATED PHARMACEUTICAL CARE CIRCUIT IN NURSING HOMES: EXCEEDING MAXIMUM DOSE PRESCRIPTIONS IN ELDERLY PEOPLE

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European Statement

Patient Safety and Quality Assurance

Author(s)

Amaia Martiarena Ayestaran, Ane Ros Olaso, Iosu Barral Juez, Cristina Saiz Martinez, Ane Latasa Berasategui.

Why was it done?

Detection of potentially inappropriate prescriptions (PIPs) exceeding maximum dose in elderly patients. Communicate these findings to nursing home´s (NH) medical staff adding information to make easier the review. Evaluate the results obtained after the pharmaceutical intervention (PI).

What was done?

Pharmaceutical care provided in NH includes systemic reviews and drug adjustments in collaboration with clinical team to enhance the rational use of drugs.
It is designed a semi-automated pharmaceutical care circuit to detect exceeding maximum dose PIPs due to high prevalence in this population. The objective of this practice is to reduce, after a PI, PIPs to improve patient’s safety.

How was it done?

Selection of the most prevalent exceeding maximum dose PIPs based on STOPP-START criteria, safety notes and technical sheets from Spanish Agency for Medicines and Health Products: omeprazole, esomeprazole and rabeprazole ≥ 40 mg/day, pantoprazole ≥ 80 mg/day, lansoprazole ≥ 60 mg/day (PPIs); zolpidem (ZLP) > 5 mg/day; acetylsalicylic acid > 100 mg/day (AAS); citalopram > 20 mg/day; escitalopram > 10 mg/day (SSRIs); iron > 200 mg/day (Fe).
Automatic data extraction.
Registration in medical records and email notification to NH´s physicians including drug and dosage, adjustment recommendation and bibliographic reference.
Results evaluation after 2 weeks.
Limitations: way of communication and drug prescribing doctor different from NH´s doctor. To solve the first issue, an email has been sent after 1 week. On the second case, no action could be taken.

What has been achieved?

155 residents with one or more exceeding maximum dose PIPs are included from 22 centers with 2,223 elderly people linked to hospital pharmacy service. The mean age is 85.3 years and 69.7% are women.
After PI, PIPs are reduced by 66.5%.

PIPs TOTAL PPI ZLP Fe SSRI AAS
INITIAL 164 73 51 18 17 5
AFTER PI 55 20 21 5 8 1

Dose reduction and prescription discontinuation are the reasons of the PIPs reductions. Physicians justify don´t change prescriptions on 8 cases.

What next?

This semi-automated circuit is focused on PIPs. That is why the tool allows easy and rapid detection of a higher amount of patients with drug safety problems at once. In the future, it will be used for other PIPs and other NH.

TRANSFORMING PHARMACY WORKFLOWS: APPOINTMENT-BASED CARE FOR ONCOLOGY AND HAEMATOLOGY PATIENTS

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European Statement

Patient Safety and Quality Assurance

Author(s)

ESTEBAN ALONSO, M TERESA; RODRIGUEZ FERNANDEZ, ZULEMA; ALAMO GONZALEZ, OLGA; GUTIERREZ FERNANDEZ, ISABEL; SANCHEZ LUQUE, LAURA; MARTINEZ TOMAS, PAULA; BENITO JUEZ, PILAR; ESPINOSA GOMEZ, M PAZ; GUEMES GARCIA, MAGDALENA.

Why was it done?

This initiative was arose from the need to improve the quality of pharmaceutical care (PC) and stock management to ensure adequate coverage for patients. Without appointments, it was challenging to align consultations with individual patient needs and to prepare medications for the time until the next visit, as patients arrived irregularly. Additionally, multiple patients on the same treatment would often visit on the same day, increasing the risk of stock shortages. This unpredictability led to inefficiencies in both patient care and stock management. The goal was to ensure a smoother patient flow, enhance PC quality, and improve stock control through scheduled visits.

What was done?

An initiative was developed to introduce a scheduled appointment system for Oncology and Hematology patients who need to collect medication from the hospital pharmacy. Previously, patients arrived without appointments, causing unpredictable patient flow and difficulties managing stock. The new system schedules patients around one hour after their medical consultations, with special arrangements for those on long-term stable treatments.

How was it done?

The main challenge was integrating the new appointment system into existing workflows in Oncology and Hematology. Close coordination between pharmacy staff, clinicians, and administrative personnel was essential. Patients were scheduled to pick up their medication around an hour after their consultations. Long-term patients, who need consultations every six months or more, were scheduled during less busy times, such as early mornings. This improved workload management in the pharmacy, ensuring more efficient and higher quality patient care. Effective communication with patients was key to overcoming early hesitation.

What has been achieved?

The system has resulted in a more predictable patient flow, leading to better PC quality through improved preparation and more efficient medication use, reducing shortages and surpluses. Patients now receive more personalized care, as workload is more balanced.

What next?

This initiative serves as an example of good practice, transferable to other hospital pharmacies and healthcare settings facing similar challenges. The next step is to verify patient satisfaction through surveys

SIDE EFFECTS OF CHEMOTHERAPY: INFORMING TO ACT BETTER

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European Statement

Clinical Pharmacy Services

Author(s)

Margot DESCHAMPS, Nejib BORGAAOUI, Jimmy ROSE, Jennifer LE GRAND, Louise NICOLAS

Why was it done?

Digestive cancers represent about 25% of new cancer cases diagnosed in France each year. The medical management of these cancers mainly relies on cytotoxic drugs. Side effects of these medications (fatigue, hair loss, nausea, or digestive issues) can affect negatively patients quality of life. These symptoms can make daily life challenging.

What was done?

As part of a patient therapeutic education program, the goal of our project was to develop an innovative educational tool to help patients better understand these side effects and find ways to manage them.

How was it done?

As part of the implementation of a multidisciplinary therapeutic education program, bringing together oncologists, pharmacists, sophrologists, osteopaths, and nutritionists, designed for patients treated for digestive cancers, the pharmacy is responsible for a workshop focused on the side effects of chemotherapy. The main molecules used to treat digestive cancers were listed, along with their most common side effects. Based on this analysis, playing cards were created, each corresponding to a specific side effect.

What has been achieved?

The developed tool is an educational and interactive board game, consisting of a board, a dice, and 56 cards. These cards are divided into 6 categories: general symptoms, neurology-psychology, heart-lungs, gastroenterology, dermatology, and real-life scenarios. The cards were designed to be understandable and accessible to all patients. The workshop takes place in two parts, with the pharmacist as the main facilitator. In the first part, patients are encouraged to share their personal experiences related to the drawn card. Then, the scenario cards are presented to help patients manage these challenges in their daily lives.

What next?

The decision was made to limit the number of participants to 6, in order to allow everyone to express themselves and exchange freely. The duration of the workshop was theoretically set at 1.5 hours but will need to be adjusted during the first workshops. It will be necessary to implement satisfaction surveys and patient follow-up on various criteria, such as emergency room visits, the number of calls after the session, and the rating of side effects.

72-HOUR TREATMENT RESPONSIBILITY AFTER DISCHARGE: CHARACTERIZATION OF MEDICATION-RELATED CALLS

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European Statement

Clinical Pharmacy Services

Author(s)

Daniel Rasmussen* and Morten Baltzer Houlind

Why was it done?

72-hour treatment responsibility (72H-TR) after hospital care is established to create a safe transition for the patient between hospital treatment and their home. After the implementation of 72H-TR, Copenhagen University Hospital, Amager and Hvidovre (AHH), experiences many calls from the municipalities related to patients’ medications. The purpose of this was to characterize calls related to medication in relation to 72H-TR.

What was done?

We reviewed logs from incoming calls made by Copenhagen and Høje-Taastrup municipalities regarding 72H-TR.

How was it done?

Calls related to patients discharged from the orthopedic or pulmonary medicine departments from AHH during the period from September to November 2023 were included. Further, two senior clinical pharmacists assessed whether calls related to medication was potentially preventable. In case of disagreement, consensus was reached between the reviews.

What has been achieved?

The results showed that 27 out of 50 (54%) calls were medication-related, and 22 out of 27 (82%) were potentially preventable. Of the medication-related calls that were potentially preventable, suboptimal communication was responsible for 11 out of 22 cases (50%), lack of a prescription accounted for 8 out of 22 cases (36%), and incomplete medication reconciliation accounted for 3 out of 22 cases (14%).

What next?

The next step will involve cross-sectoral and interdisciplinary workshops to identify barriers and facilitators and optimize the discharge process. We will also continue improving the online medication discharge reports available to municipalities to eliminate any ambiguities.

SETTING UP A LOCAL COOPERATION PROTOCOL TO ENABLE PHARMACISTS TO RENEW AND ADAPT PRESCRIPTIONS: FIRST RESULTS OF AN EXPERIMENT IN A PERIPHERAL HOSPITAL CENTRE

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European Statement

Clinical Pharmacy Services

Author(s)

S Hurel, H Benoist, N Guesdon, S Niemczyk, A-P Gaumon, A Perdriel, E Labbe
Hospital Center of Falaise, Falaise, FRANCE
sylvelie.hurel@orange.fr

Why was it done?

Implementation of a local cooperation protocol (LCP) to enable pharmacists to renew and adapt prescriptions within the hospital.

What was done?

In France, a decree published in February 2023 allows pharmacists working in hospital pharmacies to renew and adapt therapies (RAT) in a concerted manner (RATC) or directly (RATD). Previously, pharmacists could not intervene directly in prescriptions, but could only recommend changes to the prescriber, which were often time-consuming and never made. The aim of setting up this protocol was to improve patient care and optimise pharmacist and medical time.

How was it done?

The LCP was implemented on 8 July 2024 in a 600-bed hospital on three long-term geriatric test units (100 beds) following validation by the hospital medical committee in June 2024. A prospective study was carried out over three months on seven indicators: number of patients included, RATCs, RATDs, physician acceptance rates, adverse event (AE) and serious AE rates, and pharmacist and physician satisfaction rates. The indicators were collected in real time using a dynamic cross-tabulated Excel table, and satisfaction was assessed using a survey comprising five multiple-choice questions.

What has been achieved?

The number of patients included over the three months implementation period was 58. A total of 153 RATs were performed, including 53.6% (n=82) RATDs and 46.4% (n=71) RATCs. The main interventions concerned drugs prescribed but not referenced in hospital (n=38), inappropriate treatment durations (n=23) and supra-therapeutic dosages (n=18). The acceptance rate by doctors was 100% (n=153). There were no AEs or serious AEs reported. The satisfaction rate of doctors (n=3) and pharmacists (n=2) showed an overall satisfaction rate of 100% (n=5).

What next?

This three-month feedback showed that healthcare professionals were completely satisfied with the service provided by this LCP and the indicators have proved that this protocol can be applied safely. Thanks to this results, the LCP will therefore be continued in the three test units before being rolled out to other departments. Implementing this LCP in departments such as surgery will make it possible to secure prescriptions in a partnership between doctors and pharmacists.

PARENTERAL PRODUCTS: IN-USE SHELF LIFE AFTER PREPARATION ON THE WARD

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European Statement

Clinical Pharmacy Services

Author(s)

VC Lamprecht, J Pont, SD Brugger, M Dunic, T Stutz, AR Burch

Why was it done?

The preparation of parenteral medication on wards pose a hygienic challenge. It is however imperative that parenteral solutions remain aseptic, as they evade the primary barrier of the human immune defense.
The bioburden of non-preserved parenteral medications after manipulation depends on the setting. Therefore, manufacturers cannot provide guidelines on microbial stability after manipulation and hence limit the retention period to immediate use.
National recommendations concerning this issue range from cautious to restrictive, but often allow exceptions e.g. for emergency medication. These recommendations, are difficult to implement universally due to the non-transferable framework conditions from one hospital to another.

What was done?

A practical framework for the determination of retention time of manipulated parenteral medication was developed, as economic and ecological perspectives stand in contrast to the hygienic ideal.

How was it done?

International recommendations were sighted. Recommendations of the German Commission for Hospital Hygiene and Infection Prevention (KRINKO), as well as the American Society of Anesthesiologists (ASA) and The Society for Healthcare Epidemiology of America (SHEA) were used as references, as well stated sources.

What has been achieved?

Key points were identified to create a directory that enables clinical professionals to use standardized cornerstones while adapting to their individual clinical setting.
The following are indicators for the retention period in which the parenteral medication may be used: (1) primary packaging; (2) type of manipulation; (3) physicochemical properties and (4) storage temperature.

What next?

A collaboration with the Department of Infectious Diseases and Hospital Epidemiology of the University Hospital of Zurich was established to record the hospital specific conditions and to subsequently adapt the clinical practice as well as evaluate cost-effectiveness and patient safety.
Further collaborations with Swiss hospitals are being sought.

PHARMACEUTICAL CARE FOR PATIENTS WITH NASOGASTRIC TUBES: HOW SHOULD I TAKE MY MEDICATION NOW?

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European Statement

Patient Safety and Quality Assurance

Author(s)

PAULA HERNANDO MARTÍNEZ, VIOLETA LAFARGA LAPIEZA, DAVID JAMES BOARDMAN GONZÁLEZ, GRACIA PICAZO SANCHÍZ, CARIDAD MARTÍ GIL, DOLORES BARREDA HERNÁNDEZ

Why was it done?

The administration of medications through NGT is a common practice in the hospital setting. However, it cannot be assumed that this route of administration shares same properties as the oral route. Proper administration requires considering the pharmacokinetic and pharmacodynamic proper1es and adapting recommendations to the medication’s pharmaceutical form(PF). Incorrect manipulation can lead to undesirable effects, such as a reduction or loss of therapeutic efficacy, as well as an increase in adverse effects, toxicity or mechanical, metabolic, and/or infectious complications.
Despite the wide bibliography on this topic, there is a lack of knowledge among patients, caregivers, and hospital staff when there is not adequate training on the use and care of the NGT.

What was done?

Development of a pharmaceutical care project for patients with nasogastric tubes(NGT) to ensure the proper administration of medications through the tube and their correct handling.

How was it done?

In May 2024, a working group of pharmacists was formed in the Hospital Pharmacy Department (HPD) with the aim of creating a protocol for the adjustment of medications for administered through a NGT in hospitalized patients. A document was developed with general recommendations on maintenance, interactions with drugs, food and enteral nutrition, aimed at patients, caregivers and healthcare professionals to ensure the correct use of the tube. Additionally, a literature review was conducted on the various available manipulation guidelines (Technical sheets, dysphagia Guide from La Paz Hospital 2021 and the Guide for Drug Administration through Tubes Reina Sofía Hospital 2023), as well as validated apps such as (Deglufarm®, Medisonda®) which provide handling and administra1on instructions for each PF.

What has been achieved?

A daily search was conducted for hospitalized patients with nasogastric tubes to identify the need of instructions on medication handling. A fillable document was designed with the necessary recommendations for the handling of each prescribed medication during the hospitalization. During the pharmaceutical validation, patients with NGT were reviewed, and personalized reports were created according to the prescribed treatments.

What next?

To evaluate the level of patient sa1sfaction and including new needs. In addition, the aim is to implement this protocol upon discharge, in order to offer a personalized report with recommendations for the prescribed medications.