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PHARMACEUTICAL INTERVENTIONS IN PARENTERAL NUTRITION: METHODOLOGY AND RESULTS (submitted in 2019)

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European Statement

Clinical Pharmacy Services

Author(s)

Teresa Cabeças, Sara Franco, Rita Oliveira, Maria Pereira

Why was it done?

PN is an alternative or complement in patients whose oral and/or enteral nutritional intake is inadequate/unsafe or whenever the digestive tract is not functioning or this route is contraindicated. Success in choosing the most appropriate PN depends on a specialised multidisciplinary team that can provide nutritional support that results in improved clinical outcomes and patient safety. With the decision flowchart (designed in January 2019), the hospital clinical pharmacist intervenes in the calculation of the patient’s nutritional needs and, consequently, in the counselling of the most appropriate PN bag and clinical and biochemical monitoring of the patient.

What was done?

Definition and implementation of action methodology, in a form of flow chart, for patients in need of parenteral nutrition (PN).

How was it done?

Implementation of the following therapeutic decision methodology: 1. Validation of parenteral support nutritional option according to decision flowchart; 2. Filling out a patient’s nutritional needs spreadsheet −anthropometric assessment; biochemical data; calculation of protein requirements; calculation of non-protein energy needs; calculation of total energy requirements; choosing the appropriate volume; validation of the route of administration; 3. Selection of the most suitable PN bag from the Hospital Formulary (preferably after ionic corrections); 4. PN bag suggestion to the prescribing physician; 5. Acceptance and alteration (or not) by the prescribing physician; 6. Clinical and biochemical monitoring of the patient; 7. Optimisation of nutritional therapy when applicable.

What has been achieved?

From January to August 2019 the Pharmaceutical Services intervened in all 21 PN prescriptions. In this universe, 15 were in the context of gastroenterology surgery, 5 due to infection and 1 due to non-gastrointestinal cancer disease. The intervention was not accepted in only 5 cases.

What next?

Clinical pharmacists play a key role in supporting the prescription of PN. The future is challenging, particularly in assessing patients’ outcomes and quality of life, as well as the economic and financial dimension. It will also be essential to create a Clinical Nutrition Commission that covers PN, enteral and oral feeding.

DESIGN OF AN ANTI-HAEMORRHAGIC AGENTS PROTOCOL FOR AN INTENSIVE CARE UNIT (submitted in 2019)

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European Statement

Clinical Pharmacy Services

Author(s)

Mercedes Gómez-Delgado, Marta Valera-Rubio, Margarita Carballo-Ruiz, José Luis Ortiz-Latorre, Isabel Moya-Carmona

Why was it done?

Blood coagulation factors and their adequate use can be of particular importance in the treatment of massive haemorrhage, especially in the ICU. This initiative was taken in order to improve uptake and to avoid errors in the administration, which can be difficult in emergency situations.

What was done?

To define an emergency procedure that ensures correct management in cases of massive bleeding in an intensive care unit (ICU).

How was it done?

The development of drug use protocols for emergency situations is a simple task that facilitates health workers to manage them. Prioritising the drugs to be included in a protocol by a previous survey in a multidisciplinary setting is important to consider the different points of view. We carried out a review of the pharmacy service to the ICU needs of antihaemorrhagic drugs. ICU staff (doctors and nurses) were informed to reach an agreement about eligible drugs for being included in the protocol. ICU staff requested the inclusion of four drugs in the protocol according to the prevalence of use and the difficulty of administration: human fibrinogen, tranexamic acid, eptacog alfa and human prothrombin complex. We created a protocol with four information sheets, one of each drug, made of schematic information about: 1. Physical location (fridge or room temperature, number of shelf) and minimum safety stock (3 units of human fibrinogen, 4 units of tranexamic acid and 3 units of human prothrombin complex). 2. Indications and dosage according to the clinical situation and the patient characteristics (dosage adjustment according to renal or hepatic impairment, weight or age when applicable). 3. Recommendations for intravenous administration (flow rate, bolus, loading dose, dilution, mixture stability).

What has been achieved?

Mapping the information and dividing it into sections is essential for its rapid understanding in a high-stress work environment. The implementation of this protocol was well embraced by all the staff involved, since it allowed a more efficient health care circuit for the ICU staff. It also optimises the consumption of this type of more monitored drugs.

What next?

We will monitor the compliance with this protocol, as well as possible updates that may be beneficial for a better understanding of the forms of administration.

THE PHARMACIST IN THE LUNG CANCER MULTIDISCIPLINARY TEAM

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European Statement

Clinical Pharmacy Services

Author(s)

Ana Soares, Armando Alcobia

Why was it done?

Several clinical practice guidelines for LC recommend that multidisciplinary teams should be used to plan patients’ treatment. The evolution of thoracic oncology, namely the increasing knowledge of the diverse histologic and molecular phenotypes in non-small cell LC, has been driven to more complex treatment algorithms in recent years. This complexity increases the need for a multidisciplinary approach in therapeutic decision-making, which must be individualised and based on the best information available. The pharmacist’s inclusion in the multidisciplinary team is essential and was formerly proposed by the Pneumology Director to the Hospital Administration Board.

What was done?

A hospital pharmacist is a permanent member of the lung cancer (LC) multidisciplinary team, which has met weekly since January 2016, to plan the management and treatment of LC patients in our hospital. The pharmacist brings updated information about the efficacy and safety of drug treatments, its cost-effectiveness and its availability. The pharmacist improves communication with the Pharmacy and Therapeutic Committee.

How was it done?

The multidisciplinary team meets weekly to discuss the diagnosis and treatment options of LC patients, and includes a dedicated group of professionals: pulmonary oncologists, a thoracic surgeon, a radiation oncologist, a radiologist, a pathologist, a nuclear medicine specialist, a hospital pharmacist, a palliative care physician and an oncology nurse.

What has been achieved?

About 240 cases, corresponding to 200 patients were discussed per year. An average of 110 solicitations to the Pharmacy and Therapeutic Committee were made. The multidisciplinary team grants a systematic approach to diagnosis and therapeutics, in compliance with evidence-based guidelines, improves communication and coordination between professionals and short waiting times for the patient.

What next?

The next step is to systematise real-world data collecting, from the patients treated, to better understanding the effectiveness of treatment options and the real impact of the multidisciplinary team in patient outcome, ideally, extending it onto a national level.

IMPLEMENTATION OF THE FIRST MEDICINES INFORMATION SERVICE IN BELGIUM

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European Statement

Clinical Pharmacy Services

Author(s)

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

Why was it done?

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

What was done?

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

How was it done?

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

What has been achieved?

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

What next?

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