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Author(s)

Andrés Sánchez Ruiz, Rocío Contreras Collado, Lucía Gutiérrez Lucena, Juan Jerez Rojas

Why was it done?

The programme began to be developed in March 2020 as an emergency solution to the COVID-19 pandemic, but over time it was refined due to the benefits seen in different areas, especially for pharmacy patients.

What was done?

A hospital drug dispensing programme was created with the collaboration of a community pharmacy and its pharmaceutical distributor. A daily delivery was conducted from the hospital pharmacy, covering the entire province, with a population area of 622,000 inhabitants and an area of 13,500 km2 that includes widely dispersed population centres with complicated communication.

How was it done?

Interlevel collaboration between hospital pharmacy, official college of pharmacists, pharmaceutical distributor and community pharmacy. After the first year, in which the process was more manual and marked by the pace of the pandemic, the programme began to develop. A web application with two-way communication hospital-community pharmacy was created. Hospital Pharmacy reviews and dispenses these requests, with daily shipments to all community pharmacies in the province through the distributor, which ensures safe transportation of the medication with adequate conditions of humidity and temperature.

What has been achieved?

A total of 57,130 dispensations have been made since 2020 (8,089 in 2020, 14,996 in 2021, 16,629 in 2022 and 17,416 in the first half of 2023). Pharmacy Service has dispensed at least once to 5,091 patients. Thanks to the reduction of individual trips (a total of 3,529,022 kms, 52,669 hours travel time, since 2020), it is estimated that the discharge into the atmosphere of 500 tonnes of CO2 in total has been avoided, which is equivalent to the emission of 500 round-trip Spain to Denmark flights (1,000 medium-sized trees are needed for 50 years to absorb that amount of CO2). Eighty-seven percent of private car use was estimated. We did not take into account movements of patients residing in the urban centre of the hospital. The development of ICTs will allow a more clinical approach and an improvement in patient care. We also expect the improvement of the process with the creation of Patient Reported Outcomes (PROs) protocols, already underway for migraine and psoriasis, and Patient Reported Experience Measures (PREMs) protocols.

What next?

The development of ICTs will allow a more clinical approach and an improvement in patient care. We also expect the improvement of the process with the creation of Patient Reportes Outcomes (PROs) protocols, already underway for migraine and psoriasis, and Patient Reported Experience Measures (PREMs) protocols.

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Author(s)

María Isabel Sáez Rodríguez, Marta Eguiluz Solana, Marta Miranda Magaña

Why was it done?

Shortages are common in our setting. Having a list of critical and must-have drugs (CMHD) specifically designed for our centre allows us to reduce risk of complications due to delays in drugs administration.

What was done?

Monitoring and mitigating potential shortages of critical medicinal products and medical devices by redacting a list of critical pharmacy and health products to have in our centre.

How was it done?

First, we conducted bibliographic research, finding official list of CMHD by FDA, EAHP, and AEMPS.
Afterwards, we crossed those lists with the pharmacotherapeutic guide (PTG) in our centre, identifying those drugs that are considered CMHP, and checking their stock.
Discrepancies between the list provided by official agencies and our PRG were evaluated by the clinical pharmacist, taking into account our centre complexity and surroundings, nearby hospitals and type of patients attended.
With our findings, we redacted a list of CMHP specifically designed for our centre.

What has been achieved?

During our revision, we found discrepancies between our PTG and the official lists of CMHD:
• Some medicines, like certain antidotes, were not considered CMHD. These drugs were included in our list, according to intoxications incidence in our area.
• Lack of stock of must-have products in the official list. Some of them, like coagulation factors, were not considered a CMHD in our centre due to their availability in nearby hospitals. Others, like albendazole, were not included due to low incidence of disease they treated.
Evaluating each drug necessity helped us identify certain health emergencies we may come across in our centre, and prepare for them accordingly. Also, stock revision showed us which medicines have suffered from shortages in the past.
Finally, we achieved our main goal of having a specifically designed list CMHD for our centre.

What next?

Doing a revision of must-have products and adapt it to the centre’s situation enables us to have a better stock control, and serves as a back-up in case of shortages. Our CMHD list must be periodically revised, making sure it adapts to any potential changes in our centre’s situation.

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Author(s)

Laetitia ALRIC, Isabelle PLOCCO-DESMONTS, Anne-Laure DUBOIS, Sophie TOUQUET-ARNAUD, Kim NGUYEN, Blandine ARMAND, Isabelle HERMELIN, Audrey LEFRANCOIS

Why was it done?

Versatis is a lidocaine patch used in case of post-zona neuralgia. In June 2021, after a note of concern raised by the OMEDIT (Observatoires du MEdicament, des Dispositifs médicaux et de l’Innovation Thérapeutique) regarding its overuse by staff members of the CHRO (Centre Hospitalier Régional d’Orléans).

What was done?

We analysed the change in prescriptions and consumption since the implementation of a Good Practice Form (GPF) in September 2021, concerning Versatis created in collaboration with the CLUD (Comité de LUtte contre la Douleur).

How was it done?

Analysis of nominative dispensations between 09/21 and 02/22.
Consultation of shared electronic patient records.
Medical evaluation of prescriptions by rheumatology and pain-management physicians.
Methodological strategy validated by the physician in charge of professional practices evaluation.

What has been achieved?

Before the implementation, 3839 patches would have been consumed over a 6-month period versus 1541 after, marking a 59.9% decrease.
The population under scrutiny was made up of 106 patients (male-to-female ratio = 1,3; average age = 64 years). The average number of patches delivered per patients was of 15 (min=5; max=160), with 1,1 patches per localisation, for an average length of treatment of 14,4 days. 97 GPF were archived, representing 91,5% of use.
In-label prescriptions (post zona neuralgia with localised allodynia) concerned 14 (13,2%) patients.
Regarding pertinent off-label prescriptions (neuropathic pain with localised allodynia, with a maximum of 1 patch/zone/day): 36% of patients exhibited neuropathic pain, including 9% with allodynia, with 4% 1 patch/zone/day. 9,4% benefited from rheumatological or pain management consultations.
48% of prescriptions respected the 12/24h rest-time, and 79% the limit of 1 patch/zone/day off-label.
After medical expertise, 3 prescriptions were found to be unjustified – 2 due to lack of information and 1 concerning post-gout crisis pain.

What next?

Despite the patch’s small price, the implementation was of significant impact over the hospital’s consumption (and by extension, over the hospital prescribing dispensed in the community), due to its adoption by over 90% of medical prescribers. This, despite a majority of off-label prescriptions, which were rated as pertinent over 90% of the time. The GPF will have been optimised since this evaluation took place, notably with a more precise definition of allodynia.

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Author(s)

Ariadna Martin Torrente , Itziar Palacios Zabalza, María Olatz Ibarra Barrueta, Maialen Palacios Filardo, Garazi Miron Elorriaga

Why was it done?

To optimise the functioning and the management of the procedures and an accessible and effective communication system in the PS. Moreover, the quality of the shipment is guaranteed all the time. The development of a circuit has allowed being faster and more efficient during its preparation than before.

What was done?

Establishing the circuit of execution, preparation, distribution, and delivery of medicine to Non-Governmental Organisations (NGO) from the Pharmaceutical Service (PS) of a tertiary hospital in the Basque Country (Spain). The circuit has been designed taking into account the criteria in a context of humanitarian donations, published and updated by the Spanish Agency of Drugs and Sanitary Products (AEMPS) on 16 March 2022

How was it done?

Since it has been included in the daily activity of the service it has cause and increase its amount of work, hence, daily routine tasks have been slowed down, given the increase of petitions the hospital has had during last year. However, its creation has allowed being faster and more efficient during its preparation.
The circuit begins with the request of NGO, which has to be authorised by the hospital’s directory. Then, in the procedure participate pharmacists; pharmacy technicians and office clerks who prepare the donation rely on the personalised list that the donation has created. Once, the necessary documents are filled out and they are sent to the AEMPS.

What has been achieved?

From November 2021 to September 2022, 7 donations have been carried out; these contained 100 active ingredients, concretely 15.198 units. We could find most of them in the WHO model lists of essential medicines. The NGO’s destinations have been Guatemala, Romania, Ukraine and Senegal. The medications sent most according to the ATC classification were 21% anti-infective medicines, 17% cardiovascular, 13% nervous system, 12% systemic hormonal preparations and 3% alimentary tract and metabolism.

What next?

The project is easily enforceable in any Spanish PS that is willing to process a donation at any given occasion. Some of our ideas for the future are the creation of a standard list including common medications, avoiding personalised lists, in addition to connect it to our internal programme to be faster when preparing the donation.

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Author(s)

BEATRIZ MONTERO LLORENTE, ELENA GEMENO LÓPEZ, CARMEN PALOMAR FERNÁNDEZ, ANA MARÍA ÁLVAREZ DÍAZ

Why was it done?

To avoid stock breaks of medication due to unforeseeable fluctuations in their regular consumption. To reduce claims to the Pharmacy Service (PS) for medication shortages in automated dispensing systems (ADS) and other dispensing circuits. To achieve economic savings by avoiding unnecessary loans. To manage these loans in the morning when needs are detected in advance, with the consequent reduction in the time it takes for the pharmacist to manage it during on-call hours (approximately 2 hours per loan).

What was done?

We designed and implemented a tool to control in advance the stock of medication dispensed to hospitalisation and outpatient units and thus be able to forecast needs based on current prescriptions and associated habitual consumption.

How was it done?

1. An Excel file was developed in which the information on automated storage systems (ASS), ADS and prescriptions were integrated. It included maximum, minimum and current amount, and estimated coverage (in days) according to the consumption forecast associated with current prescriptions. We established the minimum amount based on a coverage threshold of 7 days.
2. Basic drug needs were studied (adjustment of maximum and minimum in the ASS and ADS, a dynamic process periodically reassessed according to demand).
3. The order information was added: order status, request date, last receipt date, order number and laboratory. These items allowed us to quickly locate old orders so we could address the reason for the delay in procurement.
4. We included medications stored externally to the ASS to control their stock electronically.

What has been achieved?

Loans requested annually from other hospitals were quantified as an indicator of improvement in acquiring medicines stored in the ASSs.
We obtained an annual reduction in the number of loans of 34.4% between 2019 and 2020 (125 loans vs 82) and 56.1% between 2020 and 2021 (82 loans vs 36). This result represented an average decrease in the time to manage loans of approximately 7 hours/month between 2019 and 2021.

What next?

The tool can be applied to all PS with ADS and ASS, intending to have the necessary medication available at the necessary time and thus avoid possible clinical damage to patients’ health derived from the delay in their treatment.

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Author(s)

Lone Møller Deleuran, Bitten Abildtrup, Sofie Pedersen, Ulrik Wøldike, Nina Winther Müller

Why was it done?

Amgros is committed to make its mark on the sustainability agenda regarding medicine – both nationally and internationally. Thereby improving access to medicines for patients in a more sustainable way – this project serves as a first step in this direction.

What was done?

In 2021, the Danish procurement organisation Amgros I/S issued the first national pilot tender for hospital medicines in which environment was an important award criterion along with price. Amgros procures 99% of the pharmaceuticals used at public hospitals. The pilot project was conducted to gain knowledge and experience about planning and executing future tenders with environmental criteria. The pilot tender was limited to the hormonal therapeutic area.

How was it done?

The chosen environmental criteria were environmental management, packaging (plastics and paper/cardboard), transportation and social responsibility.
It was a long process, including external help from consultants (The Technical University of Denmark), legal consultation, market dialogue with feedback, developing and adjusting the criteria to comply with national procurement legislation. Hence assuring the evaluation of the offers could be conducted in a meaningful, simple, and structured manner during the subsequent evaluation phase.
As a part of the final tender, a questionnaire was attached consisting of multiple choice questions concerning the environmental criteria. In the evaluation, the price weighed 80%, whereas the environmental criteria weighed 20%.

What has been achieved?

Amgros received 85 offers from 19 suppliers of which 76 offers contained the questionnaire about environment. Sixteen (84%) of the bidding suppliers completed the questionnaire. Three suppliers won the tender solely due to their environmental capability.
The tender with environmental criteria did not seem to discourage suppliers from bidding nor resulted in increasing price levels.
The pilot tender has created a great deal of awareness among the suppliers about the importance of environment and sustainability in production, distribution, and sales of medicine.

What next?

The experience obtained from this pilot tender is paving the way for the future broader implementation of more sustainable medicines in all tenders. Furthermore, the results will be shared nationally and internationally. Hopefully, the results will encourage other countries to incorporate environmental criteria in future medicinal tendering processes.

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Author(s)

Marinos Petrongonas, Maria Fragiadaki, Eleni Rinaki, Leonidas Tzimis

Why was it done?

HPs were facing challenges related to:
• Stuff shortages in a high risk environment with increasing uncertainty
• Implementation of Directive 2001/83/EC on Falsified Medicines; deadline for Greece is 2025
• Medicines’ shortages for which optimal inventory management procedures are needed • Patient safety and quality of pharmaceutical services: quality assurance processes, medicines’ traceability, monitoring expiration dates and respond-time to ward’s requests

What was done?

During the last 2 years, hospital pharmacists (HPs) actively participated in the supply, installation and functional integration of the first Automated (Robotic) Dispensing System (ADS) in Greece, in Chania General Hospital (CGH). It is a centralised distribution system installed in the pharmacy department which receives, stores and distributes packages of medicines.
It has a storage capacity of approximately 20,000 packages, including one robotic arm, three distribution exits, two loading ways (semi- and fully-automated), with software comprised. Speeds range from 200 to 900 for loading and 350 to 760 packages/hour for unloading. Under HPs’ direction, medicine management procedures were modified to ensure ADS’ functionality.

How was it done?

Since Pharmacy department of CGH was the first to install an ADS, a new route had to be inaugurated, concerning how HPs:
• Developed the proposal
• Documented and justified such a supply to be prioritised in funding
• Performed market research in Europe, as no such national market existed
• Drafted technical specifications, to assure the best system supplied
• Participated in an international tendering procedure (budget 130,000 euros)
• Planned and supervised installation and functional integration of the system
• Managed interoperability between ADS’ software and the pharmacy’s Information System
• Faced issues related to different barcodes on medicines’ packages

What has been achieved?

After 3 months of use:
• 50% of medicines’ codes and 35% of total packages are dispensed with ADS monthly
• 1.4 full-time pharmacy assistants equivalent is saved
• Response time to requests decreased
• Traceability and quality are better assured
• Falsified medicines’ check can run automatically
• Storage space is saved

What next?

HPs are ready to share nationally and internationally their experience in developing and installing an ADS with colleagues interested in adopting similar solutions. Hospitals from the same region have already shown their interest.

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Author(s)

Rachel Huey, Catherine Goudy, Michael Scott

Why was it done?

The assessment process was developed in partnership with the Business Services Organisation Procurement and Logistics Service (BSOPaLS) and regional Infection Prevention and Control (IPC) colleagues in response to the outbreak of COVID-19 and escalating demand for PPE. In March 2020, early World Health Organization (WHO) guidance formed the basis of COVID-19 PPE ensemble recommendations. Prior to the COVID-19 pandemic, BSOPaLS procured such items from reputable market leaders. However, during this time of unprecedented demand on supply chains, there were many new manufacturers and suppliers with no previous experience of appropriate supply to healthcare. There were also many counterfeit goods being placed on the healthcare market.

What was done?

During the COVID-19 pandemic, the Medicines Optimisation Innovation Centre (MOIC) utilised pharmacist skills to undertake technical assessment of all Personal Protective Equipment (PPE) items procured for use across Health and Social Care Northern Ireland (HSCNI).

How was it done?

MOIC reviewed and validated all technical documentation associated with each PPE product to ensure that items procured were genuine, fit for purpose and met the relevant standards and regulations. Benchtop assessments were carried out by IPC colleagues and BSOPaLS carried out all procurement due diligence checks on potential suppliers. Early data from 1 April 2020 to 15 May 2020 showed that only 98 (16.5%) PPE offers reviewed met the required standard for approval, while 264 (44.6%) were rejected and a further 230 (38.9%) remained open. Some reasons for rejection included documentation deficiencies and misleading labelling.

What has been achieved?

This process resulted in procurement of only safe and effective products, putting safety of HSCNI staff and patients at the forefront. In addition, BSOPaLS worked closely with local manufacturers with no previous PPE experience, to establish more resilient supply chains for the future. Products manufactured locally were also assessed via this process, to ensure suitability for use within healthcare.

What next?

This efficient assessment process has now been implemented into the PPE procurement pathway for all future HSCNI purchases, enabling the application of due diligence in a transparent, robust and evidence-based manner. Provided there is opportunity to develop an appropriate knowledge base of the relevant regulations and standards, this process is transferable across many healthcare organisations.

Author(s)

Pablo Ciudad Gutiérrez, Marta Mejías Trueba, Héctor Luis Acosta García, Maria Victoria Gil Navarro, Sandra Flores Moreno

Why was it done?

To establish a protocol for the reception, storage and dispensing of SARS-COV-2 vaccines.

What was done?

A standardised work protocol was prepared detailing the role of hospital pharmacists in the reception, storage and dispensing of vaccines, which was approved by the Head of the Pharmacy Service. A certificate of receipt was also prepared with a view to keeping a record of the number of vials received, expiry date, batch, thawing date and temperature, as well as details of each person involved in the circuit.

How was it done?

Phase 1: Preparation, approval and diffusion of the protocol in the Pharmacy Service, anticipating the imminent arrival of SARS-COV-2 vaccines.

Phase 2: Implementation of the protocol, which consists of the following protocol:

1. The vaccine distributor will contact the Pharmacy Service within 30 minutes before the delivery.

2. Upon arrival of the delivery person, the pharmacist will receive the vaccines and both parties will sign a certificate of receipt including: their full name and ID card number, the date and time of receipt, the batch number and expiry date of vials, the date of thawing, as well as the vial temperature upon delivery. This certificate will be kept by the administration staff along with the delivery note.

3. The pharmacist responsible for the reception will store the vials received in the fridge and monitor their temperature.

4. The vaccines will be handed over to the Preventive Medicine Service, the service responsible for administering them, after filling out a certificate of receipt including: date, full name and ID card number of the persons delivering and receiving the vials, number of vials delivered and expiry date. This certificate, duly completed and signed, will be filed by the Pharmacy Service administration staff.

What has been achieved?

An efficient and scheduled protocol was implemented, registering all the certificates of reception, delivery notes, as well as the temperature of the fridges containing the vials.This allowed to identify and correct errors, achieving proper use and traceability of all the vials received, resulting in increased safety for patients.

What next?

This protocol is applicable to Hospital Pharmacy Services responsible for the reception, storage and dispensing of SARS-COV-2 vaccines.

Why was it done?

The aim of the study is to assess the crisis impact on the consumption of pharmaceutical products in the intensive care unit in order to estimate, rationalize the need and prevent supply problems.

What was done?

Due to Covid-19 pandemic and its major economic impact, we carried out a comparative study of the consumption of pharmaceutical products in the intensive care unit before and during the crisis.

How was it done?

A list of pharmaceutical products to be evaluated has been established beforehand. The choice was made for the products most used in intensive care units in accordance with the recommendations of COVID management. The list includes drugs and medical devices.
In order to compare the consumption of these products in terms of quantity and cost, data collection was carried out over two periods, each of 6 months, before and during the crisis in Tunisia. The first from January 1st, 2019 to June 30th, 2019, the second from January 1st, 2021 to June 30th, 2021.

What has been achieved?

As a result of this assessment, it was possible to quantify the increase in several drugs and medical devices. It led us to:
-modulate our supply of these products
-take rationalization measures in cooperation with doctors
-develop management protocols according to the recommendations and available products
– close monitoring of prescriptions and compliance with protocols in order to optimize consumption, avoid any abuse and limit breaks as much as possible.

Tab. Variation of consumption and cost

Product Consumption2019 Consumption2021 Variation factor of the consumption Variation factor of the cost
Hypnotic curares 25 170 6.8 8.1
Antithrombotics 647 2286 3.5 8.1
Antibiotics 932 4060 4.4 11.2
Fluconazole 240 378 1.6 1.9
Dexamethasone 845 1268 1.5 2.0
Isolation gown 740 6925 9.4 7.8
Masks 6100 13300 2.2 2.2
hydroalcoholic products 123 217 1.8 1.8

What next?

A generalization of the drafting and updating of the protocols concerning the management and the dispensing is programmed for all the other departments which will be validated by the therapeutic committee and the antibiotics committee.