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Author(s)

A. ALENTADO MATEU 1 , L. ALVAREZ ARROYO 1 , R. MARTINEZ GOZALBEZ 2 , O. PEREZ OLASO 3 , R. LIMÓN RAMIREZ 4, B. MONTAÑÉS PAULS 1 .
1 HOSPITAL UNIVERSITARIO LA PLANA, FARMACIA, VILA-REAL, ESPAÑA.
2 HOSPITAL UNIVERSITARIO LA PLANA, INFORMÁTICA, VILA-REAL, ESPAÑA.
3 HOSPITAL UNIVERSITARIO LA PLANA, MICROBIOLOGIA, VILA-REAL, ESPAÑA.
4 HOSPITAL UNIVERSITARIO LA PLANA, MEDICINA PREVENTIVA, VILA-REAL, ESPAÑA.

Why was it done?

For years, Antimicrobial Stewardship Programs (ASP) teams have been working to improve the quality of antimicrobial prescription by optimizing treatments, controlling bacteremia and managing infections caused by resistant or difficult to treat microorganisms.
It is essential to have a software tool that allows real-time monitoring of both treatments and certain cultures.

What was done?

The ASP team, in collaboration with the information technology unit designed, developed and implemented a computer application at our center to support the ASP team. This application screens inpatients, searching for any of the predefined parameter alerts based on the type of antibiotic prescribed, the microorganism causing the infection, positive blood cultures or patients who are difficult to manage.

How was it done?

This alert system is based on the integration of the various hospital clinical information systems. Admitted patients are selected after a medical prescription of certain predefined antibiotics (carbapenems, daptomycin, linezolid, piperacillin/tazobactam, ceftazidime/avibactam, etc); these data are obtained from the electronic prescription programme (Athos-Prisma®). Microbiological criteria (Gestlab@ programme) include multi-resistant microorganisms (Escherichia coli, Methicillin-resistant Staphylococcus aureus), positive blood cultures, Pseudomonas, etc. Based on clinical criteria, patients who are difficult to manage can be manually included in the computer programme, mainly by the internal medicine and intensive care unit departments. The antimicrobial and microbiological criteria are dynamic and can be modified as needed.

What has been achieved?

From June 1 st 2023 to February 1 st 2024, 300 different patients have underwent interventions. In the patient’s electronic medical record from the ASP application, 355 ASP recommendations were made for 236 patients. ASP interventions included recommended isolation measures (242), modifying or suspending antibiotic treatment (68), maintaining adequate antibiotic treatment (22), initiating antibiotic treatment (11) and requesting complementary tests (12), such as imaging, cultures or serology.

What next?

This application is a fundamental communication tool for ASP teams allowings different recommendations for optimizing antimicrobial treatment to be made in the application. It automatically generates a note in the patient’s clinical history, making it accessible to all healthcare professionals and allowings for easy extrapolation to other hospitals, enabling its implementation in daily clinical practice.

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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?

Implementation of a circuit for the preparation and dispensing of elastomeric infusion pumps (EIPs) prepared in a Hospital Pharmacy Service, designed for the continuous intravenous administration of antimicrobial agents in coordination with Home Hospitalization Units (HHU).

What was done?

The purpose of this initiative is to provide an effective and safe alternative for treating infections in patients who would otherwise require prolonged hospital stays. The use of EIPs improves patients’ quality of life and reduces treatment costs by decreasing hospital admissions.

How was it done?

The Pharmacy Service contributed to the development of this initiative by studying the stability of antimicrobial agents in the EIPs, determining dilution volumes based on the maximum possible concentration, and assessing storage conditions, among other factors. The appropriate EIP was selected for each antibiotic to ensure effective and safe infusion rates. EIPs are prepared in laminar flow hoods to maintain a sterile environment during medication preparation. Additionally, educational materials for healthcare professionals were developed, and training sessions were conducted for HHU staff.

What has been achieved?

In 2023, a total of 2,223 EIPs were prepared to treat 123 patients, resulting in a reduction of 1,426 hospital days. Compared to previous years, there was a 243% increase in the number of infusers and a 131% increase in the number of patients between 2017 and 2019. Between 2019 and 2023, there was an 11.9% increase in infusers and a 36.7% increase in patients.
The antimicrobials used were: meropenem (59.6%), piperacillin/tazobactam (19.9%), cefazolin (6.8%), ceftazidime (5.6%), ceftaroline (2.2%), penicillin G (2.1%), tobramycin (1.5%), ampicillin (0.7%), acyclovir (0.6%), ceftolozane/tazobactam (0.6%), and ceftriaxone (0.4%).

What next?

Future research is expected to expand on the efficacy and safety of this methodology by studying stability times at different concentrations of agents antimicrobials to establish a sustainable model that can benefit an increasing number of patients. Additionally, patient surveys will be conducted to gather insights into their experiences and enhance their quality of life.

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Author(s)

Mette Lundberg, Mette Gulløv, Jeanette Bodin

Why was it done?

The Psychopharmacology Counseling Center (PCC) at the Psychiatric Department in the Region of Southern Denmark has been providing expert psychopharmacological counseling for nearly 10 years. Its primary mission is to offer specialized advice to both psychiatric departments and general practitioners (GPs). In addition, the team provides educational services to psychiatric departments, municipalities, and GPs, complemented by a newsletter and website that offer accessible, clinically relevant information to healthcare professionals.

What was done?

The PCC aims to promote rational and evidence-based pharmacotherapy in mental health care. This initiative seeks to demonstrate the positive impact and relevance of clinical pharmacists within both secondary and primary healthcare systems while highlighting the extensive contributions of pharmacists to the psychiatric field.

How was it done?

Data were collected on the number of questions received throughout the year, distinguishing between medical reviews and questions directed to the PCC for guidance.

What has been achieved?

The demand for psychopharmacological advice has steadily increased over the years. The team responds to nearly 60 inquiries per month at the counseling center, and conducts approximately 30 medical reviews monthly. Additionally, the newsletter now has over 400 subscribers across Denmark, extending beyond the Region of Southern Denmark.

What next?

Evaluations show that psychiatrists and GPs save valuable time by consulting specialized pharmacists. Given the demonstrated benefits, the role of clinical pharmacists should be further recognized and integrated into Denmark’s healthcare system to support effective and safe pharmacotherapy.

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Author(s)

Mia Pavelics Rehn
Trine Rune Høgh Andersen

Why was it done?

Clinical Pharmacists (CPs) in the Region Zealand Hospital Pharmacy (30 CPs) are scattered over great geographical distances on multiple hospital wards. When working with Clinical Pharmacist Services (CPS), usually just one CP is present per ward. All 30 CPs have different knowledge, seniority and specialization. To enhance the professionalism of the individual pharmacist on duty, digital communication such as chat functions are implemented for quick and easy intra-pharmacist consults.

What was done?

The ward physicians and nurses experience the combined specialty knowledge of 30 CPs from each CP when engaging CPS. This is highly relevant to maintain the position of having CPS through the hospital pharmacy instead of employing one individual CP directly on the ward, which has become more common over recent years.

How was it done?

To illuminate how the CPs from the hospital pharmacy share knowledge by using each other in their clinical operation, data was collected during three weeks of daily work. The CPs at 10 department wards registered each time they consulted a CP colleague. Furthermore, they recorded what type of communication they used (Microsoft Teams®, telephone or face-to-face) and what the inquiry was about. Written communication in Teams chat was saved for qualitative analysis.

What has been achieved?

The collected data illustrate the utilization of collective knowledge. In the three weeks 34 consults were made using primarily Microsoft teams. In 9 cases the contact was face-to-face and in 6 cases by phone. Most common was pharmacological discussion about specific cases during medication reviews (23), followed by questions about technical issues in the electronic patient record (11), general professional discussions (7) and consults about medication shortages and alternatives (8).

What next?

This initiative illustrates how using easy and available digital communication such as Teams chat functions across geographical distances will increase professionalism and harness the collective knowledge of many CPs working in collaboration for the benefit of improved CPS.

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Why was it done?

Expenditure on medicines is increasing, mainly due to the availability of expensive, innovative medicines. The admission process for expensive medicines to the Dutch market is complicated and available medicines are not always (fully) reimbursed.
At the Martini Hospital, many different parties were involved in the expensive medicines file. However, mutual coordination was limited and there was a lack of direction, monitoring and feedback of information to the prescribers.

What was done?

In collaboration with all parties involved, the process for expensive medicines has been redesigned, from application to monitoring and feedback of information to the prescribers. Responsibilities for parts of the process have been explicitly assigned and a hospital pharmacist is in charge of the process.

How was it done?

Various sub-processes have been defined: contracting, prescription and distribution, screening for new substances/indications, financial handling and monitoring. Tasks and responsibilities have been identified for each process and it has been determined how monitoring takes place.
A digital procedure for applying for new expensive medicines or indications, compassionate use programs and authorizations for individual patients has been developed.
Specific reports have been developed for each group of prescribers and are sent periodically. These reports include, for example, compliance with agreements made about preferred substances, conversion to biosimilars, and correct completion of indication codes (which are required for reimbursement).

What has been achieved?

A clear method for requesting new expensive medicines or indications has been implemented. The average processing time for a new application has decreased significantly (exact figures will be available during the EAHP 2025)
All information regarding reimbursement of expensive medicines is centrally available and transparent to all parties involved.
Physicians’ awareness and knowledge of expensive medicines has increased, and this is reflected in their prescribing behavior.
The amount of unreimbursed medicine costs has been substantially reduced (exact figures will be available during the EAHP 2025)

What next?

Continuous evaluation of the process and further development of the reports to the prescribers.

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Author(s)

Lotte Borg

Why was it done?

In the home care team (HTC), it is often assistants, who may be unskilled workers, that administer the medication from a multi-dose compliance aid. The quality control they perform before administration involves verifying that the number of tablets and capsules for the designated time slot matches what is recorded in the HTC’s digital system.
The hospital may not have all the strengths in stock, and therefore a dose can be composed of multiple or fewer tablets.
If the number of tablets deviates from the HCT’s digital system, the assistant is not allowed to administer the medicine and must call on a nurse to make sure that the hospital has dispensed the correct medicine.
This is time consuming for the HCT and the patient may receive their medicine at a later time than prescribed with consequent health effects. Furthermore the phone call between the assistant and the nurse can be worrying for the patient to hear.

What was done?

Communication with the local HCT regarding deviations from the medication list was enhanced through the use of an existing digital discharge report (DDR).

How was it done?

A DDR was already in place, and the enhancement is that nurses and pharmacy technicians now use it to report any changes in the number of tablets and capsules dispensed when discharging a patient to the HTC. A nurse from the HTC then adjusts the quantity of tablets in the HTC’s digital system based on the number of days for which the hospital has dispensed medication to be administered by the HTC.
The implementation was initiated on May 1st, 2024, in two hospital wards.

What has been achieved?

It is not technically feasible to generate a report of all the DDRs where this improvement has been implemented; however, the HCT has indicated that each time deviations are noted in the DDR, they will save a significant amount of time.

What next?

If a DDR is available and the hospital wards and clinical pharmacy department can reach an agreement on its usage and timing, there is no reason not to utilize it, especially if it can enhance patient safety during transitions in care.

Author(s)

Solís-Cuñado S. (1), Sánchez-Cerviño A.C. (2), Martínez-Núñez M.E. (1), Gómez-Bermejo M. (1), Martín-Zaragoza L. (1), Rubio-Ruiz L. (1), Onteniente-González A. (1), Molina-García T. (1)
1. Hospital Pharmacy Service, Getafe University Hospital, Getafe (Madrid), Spain.
2. Hospital Pharmacy Service, Puerta de Hierro University Hospital, Majadahonda (Madrid), Spain.

Why was it done?

The implementation of multidisciplinary antimicrobial stewardship teams(AST) in hospitals optimizes antibiotic use in order to improve clinical results, reduce antibiotic toxicity and minimize the emergence and spread of multidrug resistant(MDR) bacteria.
The objective is to present targeted interventions for the improvement of the management of lower respiratory tract infections(LRTI) and to reflect the impact of these strategies through the presentation of antibiotic use results.

What was done?

Two main interventions have been implemented in LRTI:
-Protocolize the management of community-acquired pneumonia(CAP) in order to prioritize beta-lactam plus macrolide(bLM) combination versus fluoroquinolones(FQ) monotherapy. The aim is to decrease FQ consumption due to their safety issues and the major role of this antibiotics in the emergence of MDR bacteria.
-Identify patients with severe LRTI and/or risk factors of multi-drug resistant(RFMDR) bacterial infections to encourage nasal swab screening(NSS) for meticillin-resistance Staphylococcus aureus(MRSA) to promote de-escalation of anti-MRSA antibiotics.

How was it done?

Study period: 2023 and first semester of 2024.
-CAP guideline: we studied the bLM vs FQ consumption expressed as the ratio between bLM DOT/FQ DOT (Days Of Therapy; DOT) in all hospitalized patients. Analysis was carried out on forth-month period.
-NSS: we reviewed the total number of NSS performed and the impact on duration of antiMRSA antibiotics therapy. Analysis by semesters.

What has been achieved?

After protocolization, the BLM´s DOT/FQ´s DOT ratio increased 39.4% from the beginning of 2023 until 2024: 0.66 vs 0.92.
Our AST reviewed 378 episodes of LRTI. At least one nasal screening was performed in 60.6% of episodes (n=229/378) of which 29.2% were positive (n=67/229). The mean duration of treatment with anti-MRSA antibiotics in the positive cases was 7.42 days, while in the 214 negative cases it was 6.4 days.
69% of the patients with LRTI that have been reviewed in our AST meets at least one RFMDR.

What next?

The frequent lack of diagnostic value of respiratory samples, coupled with the high percentage of RFMDR patients, results in long-lasting broad-spectrum empirical antibiotic treatments.
It is therefore proposed that a polymerase chain reaction(PCR) test be performed on candidate patients for the purpose of screening for MRSA, with a view to obtaining rapid results that will facilitate earlier antibiotic de-escalations.

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Author(s)

G.A. Vairani, B. Faitelli, B. Crivelli, F. Pieri

Why was it done?

An appropriate nutrition is a therapeutic intervention that improves clinical outcomes for each patient by reducing or preventing complications such as pressure ulcers and infections. The goal of the Hospital Pharmacy is to provide therapeutic monitoring for all nutritional therapies prescribed in the hospital and to support the optimization of pharmacological therapies associated with the specific nutrition plan. The formulary provides Physicians and Dietitians a view of the dietary products available in the hospital, allowing them to select the most suitable product based on the patient’s clinical condition. The structured request form is a valuable tool to verify that there are no pharmacological interactions between the chosen dietary product and the patient’s ongoing medications. Furthermore, it ensures that a dietitian is consulted for every prescription.

What was done?

A multidisciplinary team was established, including Dietitians, Hospital pharmacists, and Physicians, to ensure adequate and safe nutritional support for each patient. The hospital pharmacy developed a formulary of available dietary products categorized into parenteral nutrition, enteral nutrition, and oral nutrition supplements. Additionally, a customized request form for nutritional products was created. After the approval of dietitians, hospital pharmacists can proceed with dispensing, ensuring controlled distribution to hospital departments.

How was it done?

The Hospital Pharmacy first consulted with dietitians to add or remove specific dietary products from the Therapeutic Formulary, based on the most frequently treated pathologies and clinical cases. Once the products to be stocked were defined, a manual was created, listing the names, nutrient types, and administration methods for each dietary product.
For the structured request, the mandatory fields to be filled in are: patient’s identity , dietary product, dosage and duration of treatment and the dietitian’s signature.

What has been achieved?

The structured request form and the Dietary Products Manual allowed us to have a comprehensive overview of the number of patients treated with a specific dietary product and to monitor prescriptions in general, ensuring the best possible clinical outcome.

What next?

The Hospital Pharmacy will organize training days with dietitians on the selection of the most appropriate dietary product for each patient, as well as the correct handling and administration of these products.

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Author(s)

F. Castelvero, S. Borghetti, L. Savadori, D. Visigalli, C. Palladino, S. Vimercati

Why was it done?

Advanced dressings effectively treat wounds by generating a moist environment that speeds up the wound healing process, unlike traditional dressings, which base their action on a dehydrated environment and are a mere protection. Knowing how to use advanced dressings, the type of wounds to which they are addressed, their mutual interactions and their replacement times is essential to exploit their therapeutic effects. The handbook responds to the need to act as a practical guide for use in the hospital departments by nurses and physicians not specialized in wound care, to correctly treat the injured patient.

What was done?

An ad hoc handbook of advanced dressings was designed and created by our Pharmacy, in close collaboration with the hospital’s expert wound care nurses.

How was it done?

Meetings were organized with the nurses of the department of vulnology to find out the main errors observed in the use of dressings in the hospital and the fundamental dressings to purchase for the most frequent classes of wounds. The pharmacy extracted the consumption of the last year (2023-2024) from the software and drew up a list of advanced medications specifying, in simple graphic form, the indication for use, the composition, the contraindications and the interactions with other products and /or dressings and storage conditions. The dressings were divided into macro categories based on the CND of the Ministry of Health.

What has been achieved?

The handbook was reviewed by staff specialized in wound care and was presented to the physicians and nurses of the departments of destination during a training day on the treatment of wounds, with the presentation of clinical cases. One month later, a questionnaire was then submitted to the staff to evaluate the clarity of the handbook, its usefulness in normal clinical practice, and its effectiveness in treating the patient. All the staff expressed a general satisfaction.

What next?

The handbook described represents a valid tool for the correct use of advanced dressings in the hospital setting: it allows us to reduce the waste of resources, the time of hospitalization of patients, who are treated more effectively, and promotes staff training, through close collaboration between qualified nurses and hospital pharmacists.

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Author(s)

Mafalda Cavalheiro 1
Maria José Rei 1
Ana Rita Silva 1
Patrícia Batalha Silva 1
Carolina Marques 1
Miriam Capoulas 1
1- Pharmacy Department, Hospital da Luz Lisboa, Portugal

Why was it done?

Low serum Infliximab are associated with lost of response and development of immunogenicity. Moreover, therapeutic levels without the control of the inflammatory activity may inform about the necessity of changing the therapeutic class. While monitoring serum levels in the absence of response is already well established, the proactive monitoring of serum levels at defined timings during the induction and maintenance phases of therapy is beginning to be recommended by several leading organizations.

What was done?

Establishment of a protocol for proactive serum monitoring of Infliximab in inflammatory bowel disease, to guide the interpretation of serum levels, optimize dosage and therapeutic response.

How was it done?

Implementation took place in several stages. 1) Theoretical and practical training culminating in the discussion and drafting of a technical guideline including a monitoring protocol with the Gastroenterology team. 2) Organization of the sample collection and analysis circuit. The analytical technique is a rapid test that allows the detection of infliximab levels and anti-infliximab antibodies. 3) Finally, dosage optimization (maintenance of the reference dosage or intensification – shortening the administration interval or increasing the dose) is carried out with the support of population pharmacokinetic models using the DoseMeRx software, interpreted in the context of the overall response assessment in conjunction with the clinical team. The main limitation identified had to do with awareness of the medical team to rational dosage adjustments based on the population model.

What has been achieved?

15 patients were included with a median age of 33 years; 11 of these were diagnosed with Ulcerative Colitis and 4 with Crohn’s Disease. A total of 24 tests were carried out (21 with a proactive strategy and three with a reactive strategy). Of the doses taken at week 6, 60% were below the reference range considered. The dosage regimen was intensified in 64% of the recommendations. Of the patients analyzed, 76% maintained their response, although the duration of treatment was less than a year in most cases.

What next?

The strategy of proactive monitoring and dose intensification may have contributed to achieving and maintaining the response to treatment with Infliximab, but the small number of patients and the duration of the analysis call for further analysis.