ANTIMICROBIAL STEWARDSHIP: WHAT IF EVERYTHING IS ON YOUR SCREEN? (submitted in 2019)
Pdf
European Statement
Introductory Statements and Governance
Author(s)
Marinos Petrongonas, Maria Fragiadaki, Eleni Rinaki, Leonidas Tzimis
Why was it done?
Implementation of antimicrobial stewardship programmes in hospitals is part of the national strategy to promote prudent use of antimicrobials. As HPs chair stewardship teams, they are responsible for assessing prescription and monitoring antimicrobial use. Designing and developing automated informative tools facilitates HPs in their role.
What was done?
Hospital pharmacists (HPs) designed and developed software tools to support the antibiotic stewardship team’s work. Particular developments were: a) Α PC application (GrAD_calc), in Microsoft Excel, to calculate antimicrobial consumption, instead of ABC_calc tool. GrAD_calc takes advantage of the unique codes for each branded product and transforms aggregated data, provided by the Hospital Information System (HIS), into antibiotic consumption in DDDs/100 occupied bed-days. Results are presented in charts and figures, in a format that enables ease of comparative monitoring over time. b) Necessary indexes of the above calculator and documentation needed as justification for restricted antimicrobials dispensing have been integrated into the HIS; in result, data for national surveillance programme for antimicrobial consumption are automatically exported. Useful information for pre- and post-prescription review, like demographics, indication(s), co-morbidities, current and previous treatments, microbiology tests’ results, susceptibility reports, is available and easily accessible to prescribers, HPs, and infection disease specialists.
How was it done?
HPs created GrAD_calc on their own resources, while changes in HIS were made by ICT service provider, following technical specifications described by HPs. A number of technical problems have been resolved with the contribution of HPs.
What has been achieved?
• Monitoring of antimicrobial use by pharmacy is quicker and effortless. • Handwritten documentation included in restricted antimicrobials’ prescriptions has been replaced by an electronic decision support system, as tool to improve antimicrobial prescribing and stewardship. • Useful information from patient’s medical record is directly available to HPs and physicians, and facilitates hospital’s policy for assessing antimicrobial prescriptions. • Data, like indication, medicine, dosage scheme, microbiology results and susceptibility reports, are recorded electronically and update patients’ pharmaceutical records, permitting further use for pharmaco-epidemiology studies.
What next?
Next challenge is wide use of tools developed, to optimise pharmaceutical services provided and dispense restricted antibiotics only when accordingly justified. GrAD_calc is applicable in hospital setting and HIS’s tool is incorporated and can be used by all regional hospitals.
OPTIMISATION OF CANCER CARE PATHWAY OF SCHEDULED PATIENTS WHEN OUTSOURCING CHEMO SUPPLY (submitted in 2019)
Pdf
European Statement
Introductory Statements and Governance
Author(s)
Charlotte Chatain, Orane Gleizes, Séverine Barbault-Foucher, Sophie Barthier, André Rieutord, Niccolo Curatolo
Why was it done?
The production of chemotherapy of our hospital will be outsourced by September 2019. This is going to lead to new constraints including anticipated production before patients are admitted to the clinical ward.
What was done?
The clinical pathway of scheduled patients receiving chemotherapy in the main full hospitalization unit of the hospital was optimised.
How was it done?
The clinical pathway of scheduled patients was mapped to describe each step and validated by all the concerned health professionals. Data were collected between October and December 2017 to monitor the percentage of anticipated orders by physicians for chemotherapy production (also called “OK production”). Critical steps and/or bottlenecks were identified. Brainstorming workshops were set to identify areas of improvement with pharmacists, physicians, nurses and secretaries. Finally, the proposals made were implemented.
What has been achieved?
Two critical steps have been identified in this pathway: the receipt of the biological test results by the secretary and the “OK production” given by the physician. It has been decided for the secretary to call patients 72 hours (instead of 24 hours) before to remind them to do their biological test in the medical laboratory. An electronic and standardised prescription with the specific date for the biological test has also been created. In addition, a follow-up form was completed by pharmacists to secure all the critical steps and remind secretaries when they had to call patients and remind physicians when they had to give the “OK production”. Over a two months period, “OK production” given 24−48 hours before the admission increased from 18% to 40% (n= 15 patients).
What next?
These clinical pathway improvements allowed a better anticipation. The process-oriented approach used to identify solutions was very fruitful and led to collaborative solutions likely to be applied and accepted by both clinical ward and pharmacy. This method could be applied to improve other types of processes in our hospital.
MANAGEMENT OF MONODOSE TROLLEYS PREPARATION IN A HOSPITAL PHARMACY
Pdf
European Statement
Introductory Statements and Governance
Why was it done?
Because we observed an increase (20%) in the percentage of dispensing errors of drugs in the monodose process, we analysed the global pharmacy activity in our service and we observed a long processing time in preparing the monodose trolleys. Consequently, the review of the preparation of monodose trolleys was not carried out exhaustively.
What was done?
We reorganised the pharmacy service of our hospital in order to improve the total processing time and minimise the dispensation errors in monodose trolleys.
How was it done?
Through lean methodology, we analysed all the distribution tasks during the service. We used tools such as Spaghetti Chart, value-stream mapping, workflow observations, root cause analysis and the five why’s. Numerous interruptions were detected such as phone calls, movements to search for material and drugs, reworking, as well as other unnecessary work done at the same time. After this analysis, we redesigned the task’s organisation in order to improve patients’ security and reduce the process time. We modified the distribution of drugs in the preparation area; those drugs that are used more frequently are closer than the ones that are not used as regularly; a responsible to answer the telephone calls during the preparation is defined; and the hour of starting preparation is standardised. Additionally, a person in charge of supervising the process at its conclusion was designated. (The person who prepares the monodose trolleys, once work is finished, requests another member of the team to check that everything is correct.)
What has been achieved?
A significant reduction in the movements in the service, fewer interruptions and a 40% decrease in the total preparation time of the new drugs’ distribution. At the same time, the dispensation errors decreased by 35%.
What next?
Lean methodology permits the analysing and redesigning of the circuit and activity’s distribution in the service. Moreover, it is a good tool to improve the process, optimising time and reducing errors. Furthermore, the involvement of the service team is very important in finding better ways to work safely and improve circuits.
IMPLEMENTING A NATIONAL PORTFOLIO OF EXTEMPORANEOUS PHARMACEUTICAL PREPARATIONS USED IN DANISH HOSPITALS
Pdf
European Statement
Introductory Statements and Governance
Author(s)
Janne Jensen, Solvej Wandy Pedersen, Susanne Nørregaard, Karin Herkell, Anne Thestrup Nielsen, Anita Gorm Pedersen
Why was it done?
A group of hospital pharmacists representing all hospital pharmacies in Denmark have in a previous study identified and slimmed a national portfolio of extemporaneous pharmaceutical preparations used by Danish hospitals from a total of 2,754 preparations down to approximately 750 preparations being considered of clinical importance. Without a common overview of the national portfolio there will be initiated production of duplicates and almost identical products resulting in a large and inconsistent portfolio.
The purpose of this GPI was to make the national portfolio of extemporaneous pharmaceutical preparations accessible to all hospital pharmacists in Denmark and to implement a common procedure to evaluate preparations before adding them to the national portfolio to avoid duplets and obsolete products.
What was done?
A common national procedure for adding new preparations to the national portfolio was developed and implemented to avoid duplets and to ensure a uniform quality and appropriate risk assessment of the preparations.
How was it done?
A national database was developed and tested. Each hospital pharmacy entered their own extemporaneous pharmaceutical preparations in the database. Also, the extemporaneous pharmaceutical preparations manufactured by community pharmacies and used in the hospitals were entered in the database.
One hospital pharmacist in each of the five regions in Denmark was appointed as gatekeeper for the national portfolio. A template for an application form for new preparations was developed. When a physician requests a new preparation the application form will be completed by the clinical pharmacist. It is forwarded to the gatekeeper who will evaluate the preparation before approving it as a candidate for the national portfolio.
What has been achieved?
430 extemporaneous pharmaceutical preparations from the hospital pharmacies are entered and quality approved in the database. 255 extemporaneous pharmaceutical preparations manufactured by community pharmacies were entered in the database.
A national group of five gatekeepers was formed, and the workflow for both the group and the individual gatekeeper was described and implemented at all Danish hospital pharmacies.
What next?
The GPI provides an easy-accessible overview of the national portfolio of extemporaneous pharmaceutical preparations, releasing production time and resources at the manufacturing pharmacies.
SHORT, TARGETED NEWSLETTERS IMPROVE ADHERENCE TO NATIONAL TREATMENT GUIDELINES
Pdf
European Statement
Introductory Statements and Governance
Author(s)
Ane Hornbaek Mortensen
Why was it done?
Previously, a quarterly report showing adherence to national treatment guidelines was issued to all hospital administrations in our region. It was their responsibility to forward this to the appropriate specialists/consultants. This often failed and even when it was done, our experience showed that it wasn’t read by the consultants. Consequently, prescription patterns didn’t change despite the report highlighting the wards that weren’t complying with the national treatment guidelines.
What was done?
Short newsletters including graphs/tables showing the ward’s degree of adherence to national treatment guidelines were emailed to the chief consultant of the specific ward.
How was it done?
In our region a 6-person analytical team, which includes 3 hospital pharmacists, monitors adherence to national treatment guidelines issued by our national council for the use of expensive hospital medicines (RADS). Based on the results, the analytical team decides which newsletters to write. The hospital pharmacists in the analytical team are responsible for writing the newsletters and emailing them direct to the relevant specialist/consultant.
What has been achieved?
It seems as if the introduction of more targeted information has led to more rapidly changing prescription patterns. One example is oral iron chelating agents to hematological patients where a RADS guideline was issued recommending that all new patients should receive deferipron instead of deferasirox. This information was initially issued through the usual channels (via hospital administration) but no change in the use of deferipron/deferasirox was seen. This only happened after emailing a newsletter directly to the chief consultants of the three hematology wards in our region, showing the current use of deferipron/deferasirox and the potential cost reduction. Nine months and three newsletters later the percentage of deferipron use on the hematology wards increased from 2% to 27%, leading to a 22% cost reduction. Target was 25% deferipron (the guideline only covered new patients). The total increase in the percentage of deferipron use on hospitals in our region was 351% compared to an increase of between 0 and 19% in the other four national regions.
What next?
Continued and increased use of targeted communication in the health care system is required to ensure that specific information reaches the relevant players.
PHARMACEUTICAL INITIATIVE FOR APPROPRIATE HANDLING WITH CYTOTOXIC DRUG ON NON-ONCOLOGY DEPARTMENT AT OUR CLINICAL HOSPITAL
Pdf
European Statement
Introductory Statements and Governance
Author(s)
T. DIMITROVSKA MANOJLOVIKJ
Why was it done?
To highlight the classification of this drug, its dangerous side effects even to those patients not receiving it, due to intoxication when handled inappropriate, and the precautions and measures that should be undertaken to minimise the risk/danger of occupational exposure and environmental pollution with inappropriate managing of the waste and spill.
What was done?
These 4 written statements were created: (1) Notification/instructions for handling cytotoxic agentS, (2) instructions for hygienic use of the toilets by patients receiving cytotoxic therapy and disposal of toxic waste on gynaecology and obstetrics wards, (3) instructions for a woman receiving methotrexate injection and (4) standard operating procedure for intramuscular application of methotrexate for nurses in the gynaecology-obstetric ward.
All statement were copied and disseminated to all departments on the ward. In November 2014 during verification of daily drug supplies to the gynaecology-obstetrics ward, I detected a package of methotrexate injections in the transporting container together with other drugs. I immediately contacted the head ward nurse and took control of the handling of the drugs on the ward, especially in the department for pathological pregnancy. The young departmental nurse responsible nurse was not aware of the classification of nethotrexate as a hazardous cytotoxic drug that should be handled with special care. Even though a drug is not given for cancer, it should still be treated as hazardous. Explanations were given to all those present at the time: nurses, gynaecologists and hygiene maintenance staff in the department.
How was it done?
Difficulties in persuading departmental staff of the occupational hazard, intoxication by other patients not receiving the drug and environmental pollution, particularly the danger of extravasation in this class of drugs when handled inappropriately, were overcome by repeating the explanations several times and disseminating the 4 statements.
What has been achieved?
Appropriate handling of cytotoxic drugs, improvement in patient care and protection from pollution of the environment.
What next?
Frequent controls on drug handling on all hospital wards for prevention of irregularities and to ensure safe medicines application.
DEVELOPMENT OF A 7 DAY CLINICAL PHARMACY SERVICE
Pdf
European Statement
Introductory Statements and Governance
Author(s)
S. Antoniou, M. Sullivan, P. Wright, J. Quinn
Why was it done?
The cardiac centre receives over 1800 acute admissions per year, with 20% of patients admitted on weekends. National reports highlight increased mortality at weekends, which has led to a call for the NHS to provide a consistent service throughout the week1. In accordance with the European statements of hospital pharmacy2, there was a need to ensure all prescriptions be reviewed and validated promptly on admission.
What was done?
Implementation of a 7 day clinical pharmacy service to a newly merged cardiac centre.
How was it done?
A successful business case for additional resources allowed for expansion of existing service to be delivered. This facilitated change in working hours for frontline staff, including provision of a shift system ensuring the EU working time directive3 was not exceeded. Expansion of the ward based pharmacy technicians’ role to include ward based dispensing led to timely access to medicines. An increase in the visibility of pharmacy staff at the ward level facilitated a patient facing clinical pharmacy service over the 7 days.
What has been achieved?
All new admissions and discharges are reviewed at weekends with visits to coronary and intensive care. Medicines reconciliation within 24 h is above 95%. 98% of discharge medication is supplied at ward level and 93% prepared prior to discharge prescription written. Feedback from patients, nursing and medical staff has been extremely positive.
What next?
The service is currently provided for patients admitted within the cardiac services. A review is underway to consider staffing requirements to implement the service across the whole site and the trust.
RENAL PHARMACIST OPTIMISES HEALTH OUTCOMES FOR PATIENTS
Pdf
European Statement
Introductory Statements and Governance
Author(s)
A. Frisch, D. Scharlemann-Moenks, K. Heinitz, R. Frontini
Why was it done?
Limited resources require optimisation of pharmacists’ interventions (EAHP Statement 1.3). Due to the limited number of clinical pharmacists (5/1350 beds) only a few wards were served by the pharmacy. We aimed to improve the effectiveness by covering selected patients in all wards and compared the results with a classic visit.
What was done?
Instead of visiting all patients in selected wards, pharmacists focused on patients with critical renal insufficiency across all wards.
How was it done?
The central laboratory identified patients as high risk when their glomerular filtration rates were <30 ml/min, and alerted the pharmacy via email. For those patients, the renal pharmacist analysed the prescribed medication at least twice weekly throughout their hospital stay for medication errors, dosing and interactions, and suggested alternatives where necessary. Interventions were discussed either directly with the doctors or by written advice. The major obstacle was the fact that clinical services by pharmacists were unknown in most wards and that some of the doctors were sceptical about the pharmacist`s competency. We overcame these obstacles by intensive collaboration with the nephrology department.
What has been achieved?
Over 20 months involving 4229 visits, the renal pharmacist analysed the medication of 2125 patients who had 11 different drugs on average. The pharmacist assessed 47 584 medications, resulting in 2900 interventions, of which 1292 were renal and 1608 other. The most common interventions for renal patients were dosage adjustments (20%), contraindications (16%) and interactions (10%). Overall, the number of interventions (6.1% of medication items) and their severity across all renal insufficiency patients exceeded those on the visceral surgical ward (2.4%) over the same time as a comparator, confirming the higher effectiveness of the intervention.
What next?
To conduct further studies on medication safety, we established a centre for drug therapy safety in collaboration with the faculty of pharmacy with the aim of discovering valid criteria for identifying other high risk patients.
High Performance Medicines Management – HPMMF
Pdf
European Statement
Introductory Statements and Governance
Author(s)
Lars-Åke Söderlund, Marie Olsson Nerfeldt , Birgitta Elfsson
A NATIONALLY COORDINATED APPROACH TO DEVELOPING HOSPITAL PHARMACY SERVICES IN DENMARK
European Statement
Introductory Statements and Governance
Why was it done?
Approximately 450 people work within clinical and ward pharmacy in hospitals in Denmark. Despite Denmark being a relatively small country, these services have developed at differing paces, and sometimes in different directions. The initiative was set up to coordinate development and innovation in this field, across the whole country.
What was done?
A national group was established to coordinate and develop clinical and ward pharmacy services throughout Denmark. The working group consists of pharmacists and pharmaconomists representing the eight hospital pharmacies in Denmark.
How was it done?
In 2012/2013 fifteen people representing pharmacists and pharmaconomists from the five Danish regions were selected to the working group. These people were typically known to be experienced drivers of innovation and development in the field of clinical and ward pharmacy. The working group meets quarterly and additional work is carried out between meetings. There are no extra resources available to members of the group or their workplaces.
What has been achieved?
The group has produced and implemented minimum standards for ward pharmacy across Denmark. Benchmarking has been carried out using these standards and the baseline has been set. Progress will be measured regularly.
New standards for how often medicine shelf-life checks should be carried out on wards have been developed, resulting in the task being carried out less frequently on most wards, thus releasing resources to more clinically related tasks, at a time where extra resources are scarce.
Two national networking days for pharmacists and pharmaconomists have been held, where good initiatives are shared to all the regions and hospital pharmacies in Denmark.
What next?
The group is working on national standards for competency development of clinical pharmacy staff. Other logistics tasks will be scrutinized to see whether resources can be found for further investment in clinically related activities.
More benchmarking will be carried out, measuring other clinical and ward pharmacy activities throughout Denmark.
The work has just begun!