Author(s)

Joana Russo, Maria João Ribeiro, Humberto Gonçalves, Joana Ribeiro, Silva Cristina, António Gouveia

Why was it done?

In our country the oncology medication for ambulatory patients is dispensed by the hospital pharmacist (HP). Due to several aspects (i.e., COVID-19 pandemic) the process of distribution of said medication has changed in that the HP and the patient no longer meet face to face (Drive-thru systems, proximity projects in which the medication is sent to a nearby pharmacy of the patients living area). A tool was required that enabled the HPs to continue to monitor the relevant clinical aspects (patient education; medication adherence (MA), drug interactions (DI) and adverse events (AE) evaluation).

What was done?

We used a mobile application (App) to conduct the pharmaceutical evaluation of clinical aspects that need to be considered when dispensing oncology medication.

How was it done?

In collaboration with the Information Technologies department of our hospital, an App was developed. It integrates the patient’s hospital prescriptions and their answers to an adaptive query that identifies cases that need further clinical data We selected a specific drug (ibrutinib) and developed an algorithm that presented the extended questions accordingly. The App was announced to patients that required hospital medication and wanted to receive it through an alternative method of distribution.

What has been achieved?

In little over a year, a total of 1720 requests were received (668 patients). The algorithm was successful in differentiating patients whose evaluation needed to include additional clinical information. In 22 requests, further data was automatically gathered (9 patients) enabling us to evaluate MA, DI and AE. These teleconsultations do not require additional professionals (ie an assistant to register the request) nor a compatible time slot for a pharmacist-patient phone call.

What next?

The results showed that the concept of pharmaceutical teleconsultations through an App is viable and we intend to extend its range to other drugs and to dissociate the teleconsultation from the dispensing request. This approached also showed that proximity between HP and patients was positively affected allowing patients to consult their hospital pharmacist whenever they need to and wherever the patient was.

Pdf

Author(s)

SILVIA CONDE, ÁNGEL MARCOS, JOSEP TORRENT, CLARA SALOM, LAURA CANADELL

Why was it done?

Prior to the start of the project, inpatient treatments were not validated. The objective of this pharmaceutical care project was to improve the pharmacotherapy of the patients admitted to the hospital in terms of efficacy and safety.

What was done?

We implemented a pharmaceutical care project in a 153-bed regional hospital.

How was it done?

The pharmaceutical care project was based on 2 main strategies. The first of them was the validation of the treatment prescribed to inpatients according to their clinical situation. We planned to validate inpatient’s treatment from Monday to Friday during working hours.
The second one was the incorporation of the clinical pharmacist to hospital’s antimicrobial stewardship program. We established 2 meetings per week with the antimicrobial stewardship group. Revisions were focused on prescriptions of broad-spectrum antibiotics for more than 48 hours, antibiotic treatments longer than 7 days and prescriptions of aminoglycosides, vancomycin, and linezolid, among others.

What has been achieved?

During the 6 first months (January-June 2021), a total of 222 pharmaceutical interventions were performed, being the most frequent:
– “Discontinue medication” (22.97%), mainly because of “Undue duration” (31.37%) and “Therapeutic duplication” (29.41%)
– “Modify dose” (31.62%)
– “Change medication” (17.12%), mainly due to “Adjustment to antibiogram” (26.32%), “Medication exchange” (18.42%) and “Inadequate medication for the clinical situation of the patient” (15.79%).
The pharmaceutical intervention acceptance rate was 81.10%.

Related to the antimicrobial stewardship program, a total of 171 revisions were performed, making any treatment advice in 51 of them (29.82%). The most frequent recommendation was to “Discontinue treatment because of undue duration” (25.49%), followed by “Adjustment to antibiogram” (15.69%), “De-escalate treatment” (11.76%) and “Increment of antibiotic dose” (11.76%). Acceptance rate was 94%.

What next?

The pharmaceutical care program allows both the early identification of possible medication errors and upgrades in inpatients’ treatment.

Author(s)

ANA SANGRADOR, MARIA RIOJA, VICTOR MORA, MARTA VALERO

Why was it done?

reduce the variability of the process, standardize decisions, reduce medication errors, and quantify and measure results, among pharmacists who care for lung transplant patients in the hospital.

What was done?

Prepare a guide to support the pharmaceutical validation of treatment in lung transplantation

How was it done?

The circuit that has served as the script to develop the guide has been the Manual for the Preparation of Clinical Practice Guidelines in the Spain National Health System.

• Initial meeting of pharmacists with the LTx team: presentation of the need and definition of the desirable contents according to the proposals of pharmacists and pulmonologists.
• Task assignment meeting among participating pharmacists.
• Subsequent pharmacist-pulmonologist meetings to outline the aspects that could generate more doubts and controversies.
• Inclusion of the pharmacist in the TX team, to know in situ all the phases of the TX process (from the visit during the pre-TX study, going through the surgery and its subsequent recovery stage in the plant, until the subsequent follow-up in consultations).
• Put in common of the elaborated contents.
• Review by the multidisciplinary team of Ltx.
• Publication of the guide.

What has been achieved?

• Introduction to lung transplantation (LTx): idiosyncrasies of it and transplanted patients, inclusion on the waiting list, common diseases that lead to LTx.
• Most common pretransplant Disease : cystic fibrosis, autoimmune diseases, occupational diseases, obstructive diseases, etc …
• Reference laboratory values and most common deviations in LTx.
• Clinical pharmacokinetics: immunosuppressants and other drugs monitored.
• Clinical immunology of LTx.
• Pharmacology of LTx: Immunosuppression (induction and long-term), antibacterial, antiviral and antifungal infectious prophylaxis, pain treatment, prevention of osteoporosis and treatment of the most common comorbidities in post-PTx: arterial hypertension, supraventricular fibrillation, hyperglycemia and post-transplant dyslipidaemia.
• Inclusion of current pharmacological treatment protocols: initial and subsequent treatment of LTx, cytomegalovirus infection according to the donor-recipient pairing, humoral and cellular rejection, anticoagulation and osteoporosis.
• Treatment validation criteria.
• Drug-drug and drug-food interactions with clinical significance.
• Most common chronological complications in post-LTx.
• Nutrition in the post-LTx.
• Reconciliation of medication.
• Information on medicines and healthy lifestyle habits.
• Usual documentation: informed consents, uses outside the technical data sheet, etc …

What next?

This guide will help to other pharmacist.

Author(s)

Laura O’Donnell, Barry Keenan, Laura Loughran, Edel Davidson, Rosemary Donnelly, Sarah McGinnity

Why was it done?

In 2020, it was identified that diabetes specialist pharmacists working within diabetes inpatient teams were able to provide safe, effective and patient-centred care. However, it was equally identified that there was a lack of awareness of these new roles and their potential impact on care improvement. This is a major barrier to ensuring that specialist pharmacists become an integral part of diabetes inpatient teams.

What was done?

Diabetes specialist pharmacists from across Northern Ireland collaborated to define their role, and communicated their scope of practice in improving patient care as an infographic.

How was it done?

Acute hospital trusts in Northern Ireland were allocated temporary funding to demonstrate the benefits of a diabetes specialist pharmacist. There were localised differences in services provided according to the experience, and competence of the individual pharmacist, however as a team, pharmacists across Northern Ireland collaborated to help establish, develop and define the role. Work was mapped to the four guiding principles for medicines optimisation from the Royal Pharmaceutical Society Good Practice Guidance (2013). The comprehensive worklist was then transformed into an infographic to give a quick, visual and easy to understand illustration of the role.

What has been achieved?

The infographic is a unique tool to share the vision of what can be achieved by diabetes specialist inpatient pharmacists, and promotes clinical pharmacy services. The work was used to develop a business case for permanent funding, and is being used to inform a wider diabetes workforce planning strategy within Northern Ireland.

What next?

It is hoped that sharing this work will help inform and inspire teams who would like to incorporate a diabetes specialist pharmacist into their diabetes inpatient team, and provide a roadmap for those who are developing and establishing the role in their own hospital.
Next steps involve expanding the remit to include the other roles in which a diabetes specialist pharmacist can enhance care, for example outpatient clinics, and links with primary and intermediate care, to fully illustrate the role.

Pdf

Author(s)

Sarah POGGIO, Anne-Sylvie DUMENIL, Sandrine ROY, Claire HENRY

Why was it done?

BPMH on admission has been performed in these departments since 2011. An analysis of the process and prescriber use of BPMH highlighted an underutilisation; average consultation rate was 29.8%. The main reasons were the online publishing interval of the BMPH and competition with the AC report which also displays medication. A previous study showed a 70% rate of patients with unintended differences between BMPH and the AC report.

What was done?

We redesigned the pharmaceutical care process for programmed patient circuits in orthopaedic and visceral surgery by providing the “best possible medication history” (BPMH) in the patient’s electronical medical record (EMR) before anaesthesia consultation (AC).

How was it done?

Due to a lack of coordination, we exchanged using surgery with anaesthesia schedules to select patients, thus improving prioritisation. We created support documents for students, describing how to conduct a phone interview in order to reassure unfamiliar patients, to gather useful data (GP, pharmacy, prescription) to produce a BPMH, to visit inpatients when admitted to confirm the BPMH’s accuracy and to assess patient satisfaction with the process. We trained 6 students and presented our work at an anaesthetist staff meeting.

What has been achieved?

Among 195 patients included from June to October 2019, 70.2% BPMH before admission were successfully published online (137/195), 67 went through the complete care path (from home to discharging), 12 never came for AC and/or surgery, 58 were published but waiting for patient’s admission and 58 failed. The reasons we failed to publish on time included inability to reach patients (31.6%), lack of sources (21.1%), time shortage before AC (17.6%), surgery cancellation (14.0%) and refusal (7.3%). 1.58 (±0.85) calls were needed to reach a patient, 13 BPMH required modification after admission (19%), and patient satisfaction on average was 5.11/6 when asked whether the call, the medication management during hospitalisation and the confirmation interview went well. Finally, the consultation rate of BMPH evolved from 29.8% in 2017 to 72% since we changed practices.

What next?

Implementing this new process in the care path streamlines information transfer between the different stakeholders (anaesthetists, surgeons, pharmacists) and provides a better integration of pharmaceutical care in surgery wards as an efficient support system for prescribers.

Pdf

Author(s)

virginia Silvari, Suzanne McCarthy , Gerry Allen

Why was it done?

Before its establishment, patients were referred by primary and secondary care physicians to a general cardiology clinic, often resulting in delay of the initial assessment and/or commencement of treatment for AF by the ANP. The HP had no involvement in this care pathway. The AF clinic has shortened the referral pathway for patients; physicians now refer patients directly to the clinic. The HP is responsible for medication optimisation; counselling and education whilst clinicians can focus on clinical examinations, diagnostics and analysis of tests results.

What was done?

The atrial fibrillation (AF) clinic was established in a tertiary referral hospital. The clinic is led by a hospital pharmacist (HP), with expertise in cardiology and anticoagulation, and an advanced nurse practitioner (ANP) specialised in electrophysiology. Cardiologists’ input is available when required. In line with AF guidelines of the European Society of Cardiology (ESC), patients attending the clinic receive full stroke risk assessment and are presented with different treatment options by the Multidisciplinary Team (MDT). These options include heart rate/ rhythm control and stroke prevention and where appropriate DC-cardioversion. Patient’s preferences guide management of the treatment.

How was it done?

Stakeholder engagement was essential in establishing the clinic and planning meetings were used to ensure seamless delivery of the service. Analysis of the process showed that the critical path (bottleneck) was access to diagnostics on the same day of attendance of the patient to the clinic. Therefore, the clinic was established on a day where the cardiac-physiology department had sufficient resources to accommodate the clinic. It was also necessary to ensure allocated time for the ANP and HP to deliver the service.

What has been achieved?

The HP has improved patient safety by conducting medication reviews, in particular optimisation of anticoagulants according to patients’ preferences (warfarin versus direct oral anticoagulants) and their characteristics such as renal functions, body weight and age. HP also provides to the patients a one-to-one counselling session on their medications (focus on anticoagulants), adherence, drug interactions and side effects.

What next?

Having seen the benefits of this AF Clinic and the holistic service it delivers, it is recommended that hospitals establish an AF clinic to provide optimum treatment and prevent AF-related complications.

Pdf

Author(s)

Mathilde ROCHE, Niccolo CURATOLO, Marion ADLER, José POLO DEVOTO, André RIEUTORD

Why was it done?

Many smoking patients are not identified as smokers when admitted at the hospital, depriving them of any help to quit smoking. During medication reconciliation at admission (MR), the pharmacist is in a position to identify smoking patients and then offer a support programme.

What was done?

An integrated care model based on a smoking cessation programme was designed to assist smoking patients to quit tobacco. Pharmacy and addictology departments co-built and led the project. It was implemented and proposed to patients from May 2018 in three medical and surgical wards.

How was it done?

The project included five steps:
1. Training of one clinical pharmacist about smoking cessation by the addictology team.
2. Designing the process and developing tools used for a smoking cessation programme.
3. Implementing the programme.
4. Evaluating the pilot phase.
5. Developing a comprehensive training programme (including role-play sessions) for the pharmaceutical team.
The process counted six steps:
1. Smoking patients’ identification (MR, patient record, request from doctors). If the patient was polyaddicted, the addictology team was informed.
2. First patient visit: patient consent was collected, anamnesis related to tobacco and explanation about nicotine’s mechanisms and nicotine substitutes given. Appropriate nicotine substitutes were selected and tested with the patient.
3. Prescription and administration of nicotine substitutes.
4. Second patient visit (24 to 48 hours’ later): nicotine substitutes adjusted if needed.
5. Third patient visit if needed.
6. Discharge medication reconciliation.

What has been achieved?

During 4 months, 62 patients were identified as smokers during MR interviews. Twenty-seven per cent of the patients (n= 17) were sent to the addictology team because of polyaddiction, 39% (n=24) refused the programme and 34% (n=21) accepted to experience our support programme. Of these, 62% (n=13) either reduced or quit smoking during hospitalisation.

What next?

According to our encouraging preliminary results, this programme will continue to be carried on by the pharmaceutical team, while keeping a close link with the addictology team. We decided to call the patients one week and one month after discharge to better assess the performance of our smoking cessation programme.

Author(s)

F. Reidy, M. Duggan, A. Mathew, G. Duignan, S. Nasim, H. Ryder, B. Giblin, B. O’Connell, J. Corcoran

Why was it done?

The management of patients on oral anticoagulant drugs in the perioperative period has become confusing due to the introduction of:
– Newer oral anticoagulant and antiplatelet drugs
– Increased number of day case surgeries and early discharge, leading to lack of optimum care of patients, with anticoagulation and thrombophylaxis measures being undermanaged, resulting in prolonged hospital stays and cancellations of procedures.

What was done?

Following informal discussions with pre-assessment clinic (PAC) nursing staff, anaesthetists, pharmacists and surgeons, an evidence based management plan for thrombophylaxis and anticoagulation in the perioperative period for surgical patients was developed comprising of:

Thromboembolism risk assessment and bleeding risk stratification tool, to risk stratify all patients being admitted for surgery.

Prescribing guidelines on the management of anticoagulant drugs in the perioperative period.

Patient information leaflets on the management of anticoagulant drugs and thrombophylaxis measures pre and post procedure.

Preprocedure and discharge pharmaceutical plans to facilitate patients’ anticoagulation drugs to be managed effectively in the community.

How was it done?

Draft guidelines were disseminated to relevant staff and an opportunity was given for feedback over a period of 1 month. Following these recommendations, the guideline was introduced at the weekly surgical meeting. Information was then disseminated to the relevant departments.

One year later an audit demonstrated that these guidelines provided clarity with the decision making process regarding anticoagulation and thrombophylaxis, resulting in improved patient safety outcomes in the perioperative period. The need for educational training on the guidelines and simplification of the risk assessment tool was highlighted.

What has been achieved?

• Patients’ anticoagulation needs pre and post procedure can be managed with clear instructions in the perioperative period across the hospital/community interface.

What next?

The tool will be adapted to help with the decision making process regarding anticoagulation and thrombophylaxis for medical patients.
The complexities of perioperative anticoagulation are addressed in a simple way that the development of an App would benefit patient safety.

Pdf

Author(s)

S. IBAÑEZ GARCIA, C.G. RODRIGUEZ-GONZALEZ, A. GIMENEZ-MANZORRO, E. CHAMORRO DE VEGA, R. COLLADO-BORELL, E. LOBATO-MATILLA, A. DE LORENZO-PINTO, M. TOVAR-POZO, A. HERRANZ-ALONSO, M. SANJURJO-SAEZ

Why was it done?

CHC affects approximately 3% of the world’s population. The development of well tolerated and effective AADs has changed the therapeutic landscape. These therapies have a high efficacy with a good safety profile. Numerous challenges in terms of patient education, monitoring, medication errors, drug interactions and adherence exist. Our National Health System launched a strategy plan for proper CHC management in April 2015, establishing, among other things, measures to optimise AAD use.

What was done?

We have developed a pharmaceutical care programme.

I. The following protocols were defined:
– A case selection and treatment guideline, following the recommendations from health authorities.
– A protocol for the management of drug interactions.
– A protocol with recommended dosages and administration techniques.
– A protocol with potential adverse drug events and recommendations about how to prevent and manage them.
– A protocol about clinical interview to ensure patient literacy and co-responsability.
– Patients information leaflets.

II. The pharmacy department was provided with:
– 3 full time pharmacists.
– 2 patient information offices.
– a queue management system.

III. Appointment scheduling:
Pharmacy visits were scheduled after the hepatologist/infectious disease specialist appointments every 28 days.

IV. The clinical interviews were documented in the electronic health record.

How was it done?

A multidisciplinary team was formed with two hepatologists, one infectious disease specialist, three clinical pharmacists and one nurse to:
– Address the key points associated with the safe and efficient use of AADs.
– Create a useful clinical guideline.
– Identify staffing and logistics needs.

What has been achieved?

No of patients included in the programme: 674
No of initial visits: 674
No of follow-up visits: 1750
No of patients attended/day: 19.9
No (%) adherent patients at the end of treatment: 412/412 (100%)
No of pharmacist interventions: 195
No (%) pharmacist interventions accepted: 194 (99%)
Average waiting time to be attended by the pharmacist: 15 min
No of queries made to the hospital pharmacist: 84
No of adverse drug events reported to the pharmacovigilance centre: 31
Cost savings (€): 121 194

What next?

This initiative provides a set of recommendations regarding CHC management and a support guide to standardise and guarantee high quality pharmaceutical care.

The next step is to develop pharmaceutical care programmes for the management of other pathologies following the same methodology that we have used for this initiative.