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Author(s)

Line Jarvig, Louise Konradsen Refsgaard

Why was it done?

The medicine pickup lockers were implemented to offer patients in the outpatient clinics a more flexible and accessible way to receive their medication e.g., 24-hour access close to home.

What was done?

Patients who are receiving medicine free of charge from outpatient clinics traditionally pick up the medication by face-to-face contact with the nurses in the clinic every third month. Patients, who are in remission and already well-informed about their medication are offered to receive their medication in one of seven medicine pickup lockers in the capital region of Denmark. To ensure adherence, safety and optimal outcome of treatment, the healthcare professionals carefully pick out the patients, who are suited for this method. Regular contact between the healthcare professional and the patient is also continued, primarily by using digital contacts through the EPJ-system and by telephone.

How was it done?

The implementation of this new direct-to-patient distribution method was carried out by the Capital Region Hospital Pharmacy in close collaboration with the region’s hospitals and outpatient departments. The implementation requires that the clinical staff rethink their practice and accept that dispensing is no longer their responsibility. Dispensing and distribution of the medication is now handled by pharmacy staff at the hospital pharmacy’s warehouse. From here the medication is transported to the requested location and the patient will receive a text message when the medicine is ready for pickup in the medicine pickup locker.

What has been achieved?

Patients find medicine pickup lockers accessible, safe, and easy to use. Importantly, the quality of medicine dispensing is increased due to hospital pharmacy staff dispensing the medicine rather than nurses. Changing the workflow so that nurses do not dispense medicine also alleviates the shortage of nurses. In addition, this method is without doubt environmentally optimal compared to the traditionally pick up method, since transportation of both patients and the medicine is decreased.

What next?

Next step will be to offer prescription pickups at private pharmacies, which can ensure that patients can pick up their medicine at several different locations around the region and make it possible for the patients to communicate any concerns to a healthcare provider.

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Author(s)

ERMINIA CACCESE

Why was it done?

The aim is to hold a value-based tender by incorporating the clinical benefit into the competition score for the procurement of Hyaluronic Acid (AI) for intra-articular use.
The main purpose of this tender is to purchase the product with the best cost-effectiveness profile according to the Net Monetary Benefit (NMB) and putting drugs and medical devices in competition.

What was done?

In Italy as well as in Europe medical devices (MDs) procurement is based on construction features and on price. The price of MDs is not negotiated by regulatory authorities, but it’s defined by industry. Today, in a limited resources scenario, it is necessary to implement value-based procurement.

How was it done?

We used the NMB method (1) as an award criterion, a parameter that evaluates the cost-effectiveness of the therapeutic intervention.
A bibliographic search was carried out to support the chosen endpoints and the tender lots. The utility and cost values linked to therapeutic failure were sought and the minimum accepted quality was defined. The starting price was calculated per therapy cycle/patient.
Finally, a software was designed to calculate the value-based competition score.

What has been achieved?

The tender consisting of 3 lots was announced with resolution n.209/2023 (2). The technical evaluation focuses on the enhancement of the clinical benefit based on the following scores: price (30)/clinical benefit (70). The endpoints chosen for the evaluation of clinical benefit are deltaVAS and deltaEQ-5D. Both drugs and MDs can be offered for each therapeutic indication.

What next?

This tender is an example of value-based procurement that uses the evaluation of clinical effectiveness as a quality evaluation criterion.
The aim is to quantitatively link the purchase price of a therapeutic intervention to the extent of the benefit observed in clinical studies, rewarding the interventions that produce the greatest benefits. The innovative nature of our tender lies in putting drugs and MDs in competition in the same tender lot and for the same therapeutic indication, thus purchasing the product with the best cost-effectiveness profile based on scientific evidence. We are awaiting the award of the tender, the results of which we will publish shortly.

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Author(s)

Sam Coombes, Cath Cooksey

Why was it done?

Inhalers account for 3% of the total NHS (National Health Service) carbon footprint and 73 million inhalers are dispensed every year in the UK. There are legal obligations for the NHS to reduce the emissions it can influence and reach net zero by 2045, with an ambition to reach an 80% reduction by 2039. There is no national program to recycle inhalers. We wanted to establish a recycling model which is efficient and can be easily replicated.

What was done?

We established an inhaler recycling model which enables patients to drop off any inhaler at multiple healthcare settings and for these inhalers to be collected and recycled, using a pre-existing logistical model.

How was it done?

This work is part of a collaborative working project in conjunction with NHS Kent and Medway Integrated Care Board and Chiesi Limited. Alliance Healthcare are a sub-contracted service provider in the project to support with the logistical model. We wanted to demonstrate a new model for inhaler recycling using existing infrastructure aiming to improve return rates whilst keeping costs as low as possible. In Kent and Medway, East Kent with a population of 720,000 people, was chosen as a pilot area, as this presented a mixed patient demographic, and the highest volume of acute hospitals, community pharmacies and dispensing GP practices. Inhalers are collected from recycling sites made up of acute hospital sites, community pharmacies and GP dispensing practices, at the same time as medicine supplies are delivered, using a sophisticated logistical model which already exists therefore not requiring any additional transportation. Once collected by a specialist waste management company, from the wholesaler depot, the inhaler components are then recycled and gases from MDI inhalers captured and reused in other industries.

What has been achieved?

A 12-month pilot has been initiated, the infrastructure a logistical model has been put in place and data is being collected.

What next?

The data from the collection process will continue to be collated, the carbon savings calculated, and a toolkit developed so this can be easily adopted in other regions.

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Author(s)

Julie Featherstone, Alice Lo, Golnaz Douraghi-Zadeh

Why was it done?

The dashboard was initiated to provide accurate and timely expenditure data to the Medicines Value Team (MVT) which could then be appropriately interrogated and fed back to all relevant Trust and pharmacy staff. The aim was to quickly identify unexpected variance and progress on CIPs that allowed review with clinical and procurement teams.

What was done?

With the informatics team, a dashboard was developed to monitor medicines expenditure and Cost Improvement Plan (CIP) savings on a monthly basis. The dashboard incorporated varying tracking methods to provide timely data on biosimilar switching, contract price changes and individual medicine optimisation schemes at East Kent Hospitals University Foundation Trust (EKHUFT).

How was it done?

The dashboard required many hours working with the informatics team to ensure good understanding of the information required. Different CIPs had to be tracked and reported in different ways. A mixture of reporting and visual styles were needed to represent the data in a user-friendly way. It was recognised that data validation was required to ensure the accuracy of the dashboard, using a variety of recognised resources, e.g. RX Info.

What has been achieved?

A full, multi-tabular dashboard is available on the Trust Information Portal. Tracked expenditure data is reported monthly by the MVT at pharmacy and Trust meetings. This has enabled realistic and timely data to be included in overall financial forecasting and feedback to clinical teams on their CIPS. The dashboard has been designed to support the rapid addition of new schemes as they are identified to track potential savings and report at the earliest opportunity. The combined use of the dashboard with close MVT oversight has resulted in closer working with clinical and procurement teams. This has led to better identification, tracking and reporting of all medicines saving opportunities in the Trust, saving over £1 million in 2022/23.

What next?

The dashboard will continue to be developed further by the MVT to maximise the capture and reporting of CIPs at EKHUFT. It will also be used to support regular medicines value reviews with senior clinical pharmacists and their teams to help identify future medicines savings opportunities – essential in this challenging financial climate in the National Health Service (NHS).

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Author(s)

Elisabeth CESAR, Ludivine LECHEVRETEL, Adrien NIERENBERGER, Laurent DIETRICH, Anne FEGER-FALK

Why was it done?

We decided to experiment this new solution on coronarography-packs, which presents the biggest rotation among surgery-packs (5,392 units estimated for 2,023), in order to improve working conditions of logistic workers, decrease musculoskeletal disorders (MSD) and optimise storage.

What was done?

Pallet box have been implemented as a new logistic solution for surgery-packs in our hospital pharmacy on a proposal from one of our biggest suppliers. The aim of this comparative study between 52-pack pallet boxes and the previous storage solution by 4-pack boxes was to assess the potential benefit on handling work, storage, waste and its economic impact.

How was it done?

In order to compare these two solutions, we clocked the time and evaluated the cost of transport from delivery gate to storage room and healthcare-unit order-picking step (from picking up the first pack to cardboard flattening). We also estimated the amount of waste associated.

What has been achieved?

Pallet-boxes enable a 24% room saving (52 pallet-spots yearly (2 pallet-boxes piled on one spot) instead of 68) and a 31% global time saving (22 hours yearly (13h transport + 9h order picking) instead of 32 hours (17h transport + 15h order picking)). Time saving on order picking was 40%: picking step of one pack from a pallet box requires on average 6 seconds whereas 10 seconds were needed from 4-packs-boxes. Yearly 104 pallet-boxes (603 kg of empty cardboards) will be manipulated whereas 1,348 4-pack-boxes (1,213 kg) used to be handled resulting in a 2-fold decrease. Even though pallet-boxes halve cardboard-waste, they represent 1.5 times more wooden-pallets’ waste (104 versus 68). Furthermore the price of coronarography-packs are impacted by a 2% increase representing around 4,100€ yearly which is not balanced by savings on transport or order picking (10h ≈ 150€).

What next?

Logistic workers are unanimously satisfied in implementing pallet-boxes as it facilitates their work on many aspects: pallet transport, order picking, waste disposal. Despite being costlier, a decision has been made to implement pallet-boxes in the long-term in order to improve waste management and working conditions of logistic workers. Our hospital pharmacy is already thinking about extending pallet-boxes to other references in order to assess more precisely their impact on MSD in logistic workers.

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Author(s)

Lykke Henriette Sandholt, Charlotte Kok Fredslund

Why was it done?

Early in the COVID-19 pandemic, it became apparent that backorders for many medicines could arise worldwide. In Denmark, the same medicines are used in all hospitals for 1 or 2 years. As hospitals report estimates for the same drugs, it was possible to establish a national safety stockpile.

What was done?

In March 2020, Amgros established a national pharmaceutical safety stockpile for the Danish health authorities. The facility partner was approved, and the warehouse was constructed within a few months. Experience over the past three years has led to a national strategic stockpile run by Amgros on behalf of the Danish regions and Amgros.

How was it done?

Working with clinicians, clinical pharmacists, hospital pharmacies, and the Danish Medicines Agency, the range for the safety stock was identified based on defined criteria. Hospital pharmacies were also required to purchase from the safety stock. The warehouse was replaced every three to six months depending on criticality, and therefore was the risk of waste minimized. A procurement team was set up in Amgros, which established a good working relationship with pharmaceutical suppliers to identify backorders. The purchasing pharmacist regularly met with health professionals regarding drug numbers and quantity adjustments.

What has been achieved?

Throughout the COVID-19 pandemic, security of supply remained intact, mainly due to collaboration between healthcare actors, suppliers, and Amgros. The experience gained over the past three years has resulted in establishment of a national strategic stockpile. Danish regions run this stockpile in cooperation with Amgros. Selection of warehouse partner is among other things based on profitability and sustainability.

What next?

After establishing the strategic stockpile, the Danish regions and Amgros took over financial responsibility from the Danish authorities. A working group has been established, including hospital pharmacies and Amgros, to assess stock volumes at the warehouse. Medicines with unstable security of supply are stocked. Input from suppliers is highly valued. All tenders are monitored so the working group can add or delete medicines. We ensure supply when consumption is high (seasonal fluctuations). The goal of the strategic stockpile is to maintain security of supply and, thus, treatment of patients at Danish hospitals. As well as act promptly on announced and urgent backorders.

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Author(s)

Helge Ovesen

Why was it done?

In November 2022 St Olav’s hospital, a large university hospital, introduced electronic prescribing and closed loop medication for more than 700 beds. Oral medications are predominantly available as unit doses, other medications as barcoded packages. After go-live with the bedside scanning, data showed that a large part of the administrations and preparations did not happen with barcode scanning. The hospital needed to understand the reason for this in more detail.

What was done?

A team of pharmacists, nurses and IT personnel have analysed technical reasons why medications are not scanned at the patient’s bedside during administration or when doing preparation in the wards’ medicine room.

How was it done?

The group collected data on all scans that had failed and analyzed the input to the barcode scanner. In addition, the nursing staff lead was consulted to provide more information of the problems with the physical packages for the medication and how that affected the work process of achieving closed loop medication. Products that did not have a printed barcode at all were not included in the analysis.

What has been achieved?

Six different areas were identified when trying to describe the problems with closed loop medication and scanning of medicine:
1. Barcode printed on package but missing product code/GTIN in the system/national drug registry.
2. Barcode printed on package but with wrong implementation of ISO/GS1 encoding.
3. Barcode printed on package but hidden for the user on the package label.
4. Barcode only printed on the outer package that was removed when stored in the medicine room.
5. QR codes with links to training materials or other barcodes confused the nurse and the wrong code was scanned.
6. Barcode printed on package but contrast for the barcode scanning was not good enough (ex. dark vials with black barcodes).
The problems have been shared with drug manufacturers and competent authorities to raise awareness of how drug package design and correct/incorrect use of barcode printing affect implementation of closed loop medication.

What next?

Work together with national drug registries in Norway and drug manufacturers to create a national best practice for barcode printing on drug packages. The work should be coordinated with work on a European level.

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Author(s)

Anna Harjans, Dominic Störzinger, Torsten Hoppe-Tichy

Why was it done?

Nowadays, norflurane is often used as MDIs’ propellant. It has a Global Warming Potential (GWP) 1,430 times higher than CO2. Therefore, MDIs cause larger emissions than DPIs. By lowering the numbers of MDIs in-house prescriptions, savings of emissions can be achieved.

What was done?

All Metered Dose Inhalers (MDI) of our formulary were screened for the following criteria:
– Which Active Pharmaceutical Ingredient(s) (API) are contained?
– Are comparable Direct Powder Inhalers (DPI) available?
– Can MDIs be replaced by a DPI considering wards and patients’ needs?
Distribution numbers one year before/after formulary adaptation were analysed. Furthermore, subsequent savings of greenhouse gas emissions have been calculated.
Note: Different devices cause different Carbon dioxide equivalent (CO2e) emissions because of their individual product life cycle, means that CO2e-calculations are depending on the manufacturer. Thus, it is imperative to name the exact devices in this analysis.

How was it done?

Availability of comparable DPIs with the same (combination of) API(s) and dosage for each MDI was assessed for the German market. Wards with highest orders of MDIs were identified to see who may be affected by a device change. Physicians in charge were contacted to replace MDIs where possible. Subsequently the formulary was adapted.
Saved emissions were calculated on the basis of current literature [Foster® 100/6 µg: 94.42 g CO2e/puff, Foster® NEXThaler® 100/6 µg: 7.63 g CO2e/puff (Pangione, S., et al. (2020))].

What has been achieved?

One MDI (Foster® 100/6 µg) was replaced in the formulary by an equivalent DPI (Foster® NEXThaler® 100/6 µg). Distribution numbers are shown below:

– Foster® 100/6 µg: 272 (one year pre adaptation), 4 (one year post adaptation)
– Foster® NEXThaler® 100/6 µg: 150 (one year post adaptation)

By means of this our hospital pharmacy reduced emissions by 2.921,9 kg CO2e compared to preadaptation.

What next?

MDIs containing new propellants with lower GWP are already being worked on by the pharmaceutical industry and thus, more climate friendly opposed to conventional MDIs. Replacing current MDIs with the novel, climate friendly alternatives once available on the market is a useful approach to further lower hospital pharmacies’ carbon emissions.

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Author(s)

Outi Lapatto-Reiniluoto, Suvi Sivula, Elina Ahomäki

Why was it done?

Price has been the most prominent criteria in procurement quality being the second. Environmental aspects haven’t been assessed earlier. Differences between the pharmaceuticals’ environmental burden can be considerable and by choosing wisely we would be more sustainable.

What was done?

Environmental criteria have not been used in Finland in hospital procurements earlier. We created the criteria which would be acceptable to all parties (hospitals, suppliers), would be reliably assessed, and easily copied to other hospitals.

How was it done?

Our tender had six questions for everyone and two more questions for antibiotics or hormones. The common questions were answered by yes / no / we do not know. Points given were 0, 1, 2. An example of the common question is: Does the company have a plan how to reduce CO2 emissions caused by itself?
Questions for antibiotics and estrogen hormones were: Company has told in which country and in which plant the API is produced and the formulation happens.

What has been achieved?

132 providers answered so far. Quality of answers varied considerably, from 0 to 12 points, mean 7 points. Questions for antibiotics created the most discrepancies: 41 providers; 15 were not able to answer these questions acceptably. The answers showed that the questions were not too difficult, these questions could be answered, and the answers can be analysed.

What next?

The criteria were very simple and assessing the answers was not difficult. Only one question was widely misunderstood. Questions were universal and can be used in other hospitals, too, which is the wish from the industry (same questions everywhere). Wide range of results showed differences between the companies. During this round we did not give any credit for the best products but in the future more responsible products should be rewarded. Antimicrobial resistance e.g., is a global problem but if the company does not know where its products are manufactured how can they look after wastewater treatment of their products.

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Author(s)

Margaux DUFOSSE, Claire ANDREJAK, Abir PETIT

Why was it done?

By May 2022, we learned about the sale discontinuation of oxygen humidifiers from one of the two manufacturers in our country, due to the constraints of MDR 2017/745. The second manufacturer restricts its products to hospitals with marketing partnerships. In our hospital, oxygen humidifiers are used regardless of the oxygenation medical device (nasal cannulas, masks, tubes or tracheotomy tube) or oxygen flow rate. We had to define indications and prescriptions to control consumption in our hospital.

What was done?

To promote good use of oxygen humidifiers and control our consumption in a context of shortage we have drawn up a scientific explanatory document, a procedure and a prescription support.

How was it done?

We suppressed services’ allocations for humidifiers, to encourage prescription via the Electronic Patient Record. We set up a working group, including pharmacists, resuscitators, pulmonologists and nurses, to write a good use sheet, underlining high-priority medical indications taking account of scientific literature and respiratory medicine learned societies’ recommendations. To assess its effectiveness, we compared humidifiers’ consumption before and after we set it up and evaluate prescriptions’ number and conformity for the first 4 months, from May to September 2022.

What has been achieved?

The group restricted indications to paediatric patients, patients with tracheotomy and patients with oxygen flow rates above 5L/min and upper respiratory tract lesions such as nose bleeding, nasal discharge congestion, or nasal mucosa’s irritation or lesions. We wrote the good use sheet, mentioning the circuit’s montage and conditions for dispensing humidifiers. Before the new procedure, the mean consumption was 1,415 units per month, versus 39 per month from June. Regarding prescriptions’ conformity, 12 (8.7%) out of 138 were denied: six patients on ambient air, four with nasal cannula, one without any severity criteria, a not nominative prescription.

What next?

This collaborative and multidisciplinary work enabled a change in practices. Supply difficulties, initially seen as challenging, are a great opportunity to promote good use, and secure patient care. Although they have now been resolved, with a new supplier, we maintain our measures to ensure patients’ security and well-being.