Pdf

Author(s)

NOELIA VICENTE-OLIVEROS, CARMEN PALOMAR FERNANDEZ, TERESA GRAMAGE-CARO, PAULA BURGOS BORDEL, MARÍA DEL CARMEN CALATAYUD SÁNCHEZ, SANDRA CASADO ANGULO, ANA MARTÍN ÁLVARO, MARÍA BEGOÑA RIVERA MARCOS, SONALI KARNANI KHEMLANI, MANUEL VELEZ-DIAZ-PALLARES, ANA ALVAREZ-DIAZ

Why was it done?

Patients with moderate-severe psoriasis require systemic hospital-dispensed treatments. Hospital pharmacists look for actions to anticipate patients’ needs for achieving health outcomes and the system’s sustainability.

What was done?

We stratified psoriasis patients according to the pharmaceutical care needed and established their pharmaceutical care plan. We calculated the time needed in pharmaceutical care after stratification.

How was it done?

An observational, prospective, cross-sectional study was conducted in a university hospital. One hundred psoriasis patients who received medication in the outpatient hospital pharmacy were randomly chosen between March-May 2022.
Capacity-Motivation-Opportunity (CMO) pharmaceutical care model (SEFH, 2018) was used to stratify patients. This model consisted of 23 variables (demographic, clinical, pharmacological, socio-sanitary, cognitive and functional). Each variable scored between 1-4, depending on patient risk. Patients were classified on three levels which determined the subsequent pharmaceutical care to be provided to each patient:
1. global score≥31 points,
2. 18-30 points and
3 ≤17 points.
Information was collected through patients’ interviews and electronic health records review.
A group of nine pharmacists were set up to adapt the CMO pharmaceutical care model to our hospital.
Total time spent in pharmaceutical care was obtained through patient visits before and after stratification. The scheduled average time for each visit was 10 minutes. The number of visits pre-stratification was the sum of all the visits scheduled for the patients, and for post-stratification was the sum of all the visits with the new CMO model (level 1 (biannual), 2 (annual), 3 (as needed).

What has been achieved?

Most patients were stratified on level 3. A pharmaceutical care plan has been designed to meet the needs of each patient.
Stratification has improved the time pharmacists have to accomplish the needs of each patient (16.3 hours/year (98 visits)). Sixty-two percent of patients had as needed visits (level 3), 36% needed annual visits (level 2) and 2% biannual (level 1). However, during pre-stratification, most the patients (70%) had every nine months visits, 18 % every 12 months, 9% every six months and 3% every three months.

What next?

We will expand the stratification to the rest of the psoriasis patients and other outpatient pathologies.
We will coordinate strategies with Social and Psychological Services, Primary care and Community pharmacy to improve pharmaceutical care.

Pdf

Author(s)

Andrea Bor, Nóra Gyimesi, Eszter Erika Nagy

Why was it done?

Intervention-oriented classification systems are helpful tools to document the CPIs in a structured manner. Our aim was to develop a clinical pharmacy platform in the e-documentation system at our institution. This CPI data enables healthcare providers to track medication history, and to systematically analyse the effectiveness and the pharmacoeconomic benefits.

What was done?

A pilot survey was conducted on the traumatology wards to analyse and describe our clinical pharmacist interventions (CPI) based on severity and clinical relevance.

How was it done?

Three clinical pharmacists collected data on the changes of drug therapy at two 31-bed traumatology wards during pre- and postoperative period. We adopted the CPI classification system to our daily practices. This is challenging since the narrow time frame between patient admission and discharge often limits the opportunity to provide clinical pharmacy services. Raw data was previously screened and classified into 5 categories, drug related problems (DRP), clinical pharmacist intervention (CPI), significance (S), outcome (O) and acceptance (A).

What has been achieved?

We have established a data collection process, which allows us to record CPIs in our daily clinical environment in an efficient manner.
The most significant DRPs were incorrect dosage regimen (n=47), untreated indication (n=28), contraindication (n=25), excessive dose (n=19), subtherapeutic dose (n=17), drug interaction (n=15), no indication (n=11), experiencing adverse drug reaction (n=8), failure of drug administration due to shortages (n=5).
CPIs were divided into four groups:
1. Pharmacokinetic cause (dose adjustment, changes of drug dosage regimen, drug discontinuation, drug switch, etc.)
2. Pharmacodynamic cause (adding new drug, drug switch, – discontinuation, etc.),
3. Providing drug information (patient education, new drug, changes of administration route, etc.) and
4. Miscellaneous.
Significance were categorised as major (e.g. oral anticoagulant – LMWH switch, postoperative opioid use), moderate (e.g. loop diuretics – ion supplementation), minor.
Outcomes were therapeutic success, prevention of potential harm (e.g. adverse drug reaction) or cost saving.
73% of the interventions were accepted, the rest were rejected for the first time, but nearly half of them were admitted after minor modifications.

What next?

This CPI platform should be shared in the national digital health system.

Pdf

Author(s)

Iris Summer, Marina Zakhari-Betros, Alice Poier, Christine Fegerl-Stadlober

Why was it done?

There had been reports from healthcare professionals of the presence of undigested tablets in ostomy pouches and reasonable doubts of adequate drug absorption. In addition, there were recurring inquiries from clinicians about drug related problems in ostomy-patients.

What was done?

Implementation of a clinical pharmaceutical service for patients with an intestinal ostomy following their stoma-surgery. In this service, oral drug therapy of patients with either ileostomy or colostomy was assessed to determine whether possible impairment of drug liberation or absorption could lead to malabsorption of drug therapy.

How was it done?

A project was conducted, where 30 ileostomy and colostomy patients were observed. Simultaneously, a literature review concerning all orally administered drugs of this patient collective was done. During the project time, two interviews were done with the patients. The first one was lead during hospitalisation whereas the second one was conducted within 4 weeks after hospital discharge. To standardise the interviews, two different questionnaires were developed. Medical status of the patient as well as pharmacokinetic properties of the drugs administered orally were thus assessed. It was evaluated whether there are any drugs which may feature any impaired drug liberation or absorption. In case of anomalies presented, such as undigested tablets found in the pouch, a plasma level measurement of the drug was done, if reasonable. In addition, the subjective perception of the patients was also taken into account, to measure whether malabsorption of drugs is recognised or not and if patients are aware of possible impairment of absorption.

What has been achieved?

A strategy was established to help healthcare professionals assess oral drug therapy in ostomates. In addition, awareness in healthcare professionals as well as patients was raised, concerning possible impaired drug liberation because of the use of inappropriate dosage drug form. Moreover, prevention of prospective drug related complications was also achieved.

What next?

1. Modification of our electronic medical record concerning automated pharmaceutical counselling.
2. Integration of a clinical pharmaceutical service within the ostomy care service of our hospital to provide better therapeutic outcome, especially when ostomy-related problems are presented.
3. Providing patient information leaflets to improve health literacy and patient satisfaction.

Pdf

Author(s)

Daniele Mengato, Laura Camuffo, Anna Zanin, Fernando Baratiri, Barbara Roverato, Franca Benini, Francesca Venturini

Why was it done?

PPC patients are children with chronic or terminal illnesses requiring a high intensity of care. Because of their criticality, a strict clinical monitoring is needed, as well as personalised therapeutic strategies.

What was done?

The paediatric palliative care (PPC) unit aims to provide paediatric patients with the best possible care in the management of their disease to ensure the optimal quality of life. The pharmacist has joined the interdisciplinary team with the aim of improving drug management in both acute inpatient and chronic therapies.

How was it done?

From August 2021, the clinical pharmacist joined the PPC staff with the aim of improving medicine management. The pharmacist, primarily, took charge of the medication review process. Individual therapies were periodically reviewed by the multidisciplinary team on the basis of admissions and clinical changes. In addition, a formulary manual for healthcare professionals was drafted, with the description of the crushability of the most commonly used pharmaceutical forms in clinical practice by collecting and keeping up-to-date information from national and international handbooks.

What has been achieved?

Over the past eight months, initial drug reviews have been carried out for all 169 patients followed by the PPC unit, with collegial re-evaluations cyclically carried out for the most critical patients (15). These patients had at least 10 drugs to take each day and therefore assessments were made to simplify treatment regimens by providing 37 suggestions to physicians with the aim of reducing the risk of interactions and facilitating home therapy management. With regard to the handling of pharmaceutical forms, many galenic formulations have been proposed in order to reduce the crushing of solid forms as much as possible. Most of the suggestions were discussed and accepted by the medical team.

What next?

Clinical pharmacist’s intervention is crucial in the management of terminal or chronic therapies for critically ill patients. Next step will be the analysis of caregivers’ care burden, through a specific questionnaire that has already been validated, so as to improve the home management of this particular category of patients.

Pdf

Author(s)

NURIA FERNANDEZ PIÑEIRO, CRISTINA GONZALEZ PEREZ, LIDIA YBAÑEZ GARCIA, NATALIA SANCHEZ-OCAÑA MARTÍN, JOSE MANUEL MARTINEZ SESMERO

Why was it done?

In our area all care for PrEP users was centralised in a specialised centre. Here, a multidisciplinary team made up of doctors, nurses and pharmacists integrated in a patient-centred care model. PrEP users are a potentially vulnerable population. Health education and motivation are provided in the PhC consultations to raise awareness about the use of medication and adherence to treatment, which are key to avoiding HIV infection. The use of sex-related drugs is a growing health problem in this population and has been associated with increased HIV transmission risk.

What was done?

Development and implementation of a monographic pharmaceutical care (PhC) consultation for human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) users.

How was it done?

On 20 January 2020, the PhC consultation was launched in a monographic STI care centre linked to a tertiary hospital.
– On the same day as the first medical appointment, the user attends a PhC appointment. In this unit the user receives the necessary information to properly take the medication. Possible interactions are reviewed, not only with medications, but also with natural medicine, sports supplements and drugs. All doubts are resolved and the medication is dispensed.
– Every 3 months medical follow-up is carried out and, in the PhC consultation, where not only possible adverse effects are reviewed, but also adherence and related problems are specially monitored. To increase the quality of care, active communication between all health personnel was ensured.

What has been achieved?

Until 30 September 2022, 3,460 initial visits and 13,349 follow-up visits have been made (411 of them through telepharmacy during the lockdown as a result of the global pandemic by SARS-CoV-2). From the users, 98.98% were men who have sex with men (MSM), 0.80% transgender women, 0.04% transgender men and 0.18% were women. 70.3% used sex-related drugs (Chemsex), with the most used substances being Popper (37.1%), mephedrone (28.2%) and gamma hydroxybutyrate (GHB) (24.6%).

What next?

In our experience, the role of hospital pharmacists as a reference health personnel for HIV-PrEP users has become clear, not only as an expert in medication. Given the prevalence of drug use in this population makes the health education that we hospital pharmacists can provide especially important.

Pdf

Author(s)

Alba Manzaneque, Carla Jurado , Cristina Alonso , Mireia Cairó, Glòria Molas, Fernando Salazar , Lucía Boix, Roser Font, Laura López, Jordi Nicolás, Marc Campayo, Esther Calbo

Why was it done?

Although an intrinsic risk of infection has not been associated with ICI, there are different studies and case-series in the literature in which an increased risk of infection is observed, mainly associated with the use of immunosuppressive drugs (like corticoids) for immune-mediated toxicities. The objective of implementing this circuit in our centre is to reduce all preventable infections, by carrying out an initial infection screening that allows detection of those patients susceptible to vaccination measures, prophylaxis, or specific recommendations.

What was done?

Implementation of an infection screening circuit in cancer patients treated with immune checkpoint inhibitor drugs (ICI).

How was it done?

To carry it out, a multidisciplinary work team was created (pharmacy/oncology/infections department) that designed the ICI template and the clinical circuits. At this point, we believed it was necessary to centralise requests, results, and follow-ups in the oncology pharmacy team (OPT) in order to ensure that all patients were included.
Before the patient initiates treatment with ICIs, the OPT makes the request for a pre-established ICI analysis and the oncology nurse (ON) extracts it. Within 7-10 days, the infection department checks the results and makes the necessary recommendations (vaccination/prophylaxis/specific recommendations).
The OPT is then responsible for both vaccination and initiation of prophylaxis.

What has been achieved?

A total of 30 patients (January to September 2022) have been included in the circuit, 25/30 being men and with a mean age of 67.8 (± 8.8) years.
In 25/30 the treatment was with palliative intent, and 21/30 had lung neoplasia.
The ICIs prescribed were: pembrolizumab (15/30) and nivolumab/atezolizumab/durvalumab (5/30 in each case).
Screening results are available for 26/30 patients. Some type of recommendation was made in 25/26 patients, being: 20/26 hepatitis B vaccination, 5/26 start prophylaxis (2/5 hepatitis B and 3/5 tuberculosis), 6/26 hygienic-dietary measures (aimed at toxoplasmosis).
Additionally, all previously unvaccinated patients (23/26) have been vaccinated against pneumococcus.

What next?

A comparative analysis of infection with a historical cohort is planned when larger sample size is available, to demonstrate that these types of measures reduce the occurrence of infections. Centralising this type of initiative from the OPT is key to our integration into clinical teams, by avoiding important adverse reactions and taking care of our patients.

Pdf

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.

Pdf

Author(s)

Suzanne Al-Rawi, Sadeer Fhadil, Sotiris Antoniou, Rodnie Oro, Paul Wright

Why was it done?

It is suggested that 40-80% of information provided by healthcare professionals is forgotten immediately by patients (1). The trust has a checklist of counselling requirements for anticoagulants, completed in consultations with patients before discharge. Recognising the complexity of anticoagulation counselling and its time constraints, we sought to assess the use of pre-recorded counselling videos for use at ward level and as a resource for patients to refer to post discharge.

What was done?

We sought to develop anticoagulation counselling videos for ward use, with hyperlinks for patient access post-discharge. We aimed to improve information provided to patients and optimise pharmacists’ time undertaking counselling.

How was it done?

Using a patient focused questionnaire, feedback was sought on patient satisfaction as well as time totality following anticoagulation counselling. A series of short and digestible video clips (1-2minutes each) that reflected the trust checklist were recorded. The videos were played to the patient and then a follow-up face-to-face consultation was undertaken to answer any questions. Patient satisfaction and time taken was assessed through the use of the questionnaires and compared to consultations without the pre-recorded clips.

What has been achieved?

Over 4 weeks, 121 patients received anticoagulation counselling. 77 patients were counselled using videos and compared to 45 patients counselled without videos. There was a 70% reduction in time spent; an average face-to-face counselling required 24 minutes, compared to only 7 minutes if the patient had seen the videos. There was an overall increase in patient satisfaction with use of videos to 86% from 70%.

What next?

We have shown optimisation of the anticoagulation counselling process through the use of pre-recorded videos. Time spent counselling has been significantly reduced and feedback from pharmacy staff has suggested more patient-centric counselling is achieved. It has allowed for information to be standardised, with an increase in patient satisfaction and understanding. Patients have access to the videos on discharge to improve patient safety. There have not been any reported incidences since switching methods. There has been a reduction in patient queries related to anticoagulation post- discharge. Areas for further development include dubbing of the videos to several languages to improve access to all.

Pdf

Author(s)

Catarina da Luz Oliveira, Maria Augusto, Carla Ferrer

Why was it done?

Ideally, clinical pharmacy should be performed continually and not only at the Pharmaceutical Consultation. The usage of technologies as new communications channels between patients and pharmacists would contribute to this notion of continuous clinical pharmacy, so we started to develop the app PharmaClick. With this app, the pharmacist will be able to remotely monitor the patient therapy, to mitigate medication errors, to control adverse drug reactions, to detect possible drug interactions, and to promote therapy adherence.

What was done?

We are developing a web application called PharmaClick. This app will allow the patient, after the respective Pharmaceutical Consultation at the hospital outpatient clinic, to communicate on time with his pharmacist and to give access to several features related with his medication.

How was it done?

The app PharmaClick is being developed using open source technology, Ruby on Rails, and is currently in a small-scale implementation to prove the viability of the project.

What has been achieved?

The PharmaClick app is now a pilot project and is being used as support on the Pharmaceutical Consultation. The patient is invited to download the app PharmaClick and he is introduced to its features, such as:
• How to identify his medication and dosage;
• How to set alarms for taking the medication and making the respective register, allowing the pharmacist to check the therapy adherence rate;
• How to request the scheduling of a new pharmaceutical appointment;
• How to communicate with the pharmacist using the chat to clarify some doubts that he may have after the appointment;
• How to register possible adverse drug reactions;
• How to submit the quality of life form, which will allow to indirectly measure the therapy efficiency.

What next?

The project is sustainable since it is easily applied on other health institutions. The app allows to anticipate possible medication problems. The goal is to provide health solutions that are remote and effective, to improve the patient participation in the healing process and in his wellbeing in the long run. The treatment success is easily improved at the distance of a PharmaClick.

Pdf

Author(s)

Florian Poncelet, Cedric Mwamba, Valentine Foulon , Anne-sophie Da Silva Rego, Catherine Floret

Why was it done?

Medication adherence of post-stroke treatments is important in preventing stroke recurrence. Problems of adherence with these medications are frequently encountered. Patient education is therefore essential in the management of this pathology.

What was done?

The creation of tools for the medication session of the post-stroke therapeutic education programme and the measure of the activity impact on patients’ knowledge of their treatments.

How was it done?

The session is led by a pharmacist in the form of a Game of the Goose, with the cards divided into 3 different colours, each corresponding to one of the 3 categories seen during the activity: General Questions, Statins and Anticoagulants/Anti-aggregants. This form allows participants to learn in a fun way and to promote interactions.
To evaluate the impact of these sessions, the same quiz is filled out by the patients at the beginning and end of the session, in order to measure the improvement of their knowledge. This quiz is in the form of an evaluation grid, composed of 20 questions with binary answers (True/False) covering the concepts discussed during the activity. The answers allow the attribution of a grade out of 20.

What has been achieved?

33 game cards were created (12 cards for general questions, 8 for statins and 13 for anticoagulants/anti-aggregants, of which three concern anti-vitamin K).
The patients take turns drawing a card and think collectively. The correct answer is later explained by the pharmacist. At the end of the activity, forms summarising the points discussed are given to the patients.
Concerning the quiz, the evaluation of the impact of these sessions was carried out on a first group of seven patients. The average score was 14 (12-17) at the beginning of the activity and 17 at the end (15-20), thus an average improvement in knowledge of 21% (0-58%).

What next?

An analysis of the questions with the lowest rate of positive responses will help us to improve the messages during the activity. A treatment plan given to patients at the end of the session to help them take their medication is also being discussed.