Author(s)

Morgane HOUIX, Valérie VIAUD, Cécilia HURLUPE, Yannick POIRIER

Why was it done?

The pooling of stock for the 5 rooms required a referent for stock management. In order to free up caregivers from the administrative and logistical tasks related to pharmaceutical products, pharmacy has been directly integrated into the project of ITP.

What was done?

In May 2021, interventional cardiology, rhythmology and coronary angiography have been gathered in an interventional technical platform (ITP) of 5 operating rooms. A full-time hospital pharmacy preparer (HPP) position has been set up within the ITP.

How was it done?

For the success of the project, the 2 chosen PPH had to easily becoming part of ITP’s teams and must learn specifics of medical devices of each speciality. For this purpose an immersion in each sector was carried out during the installation of the ITP and continues today by participating in interventions. They shared in the process of installing the PTI’s arsenal of pharmaceuticals with careteams by grouping the initials allocations of products of each speciality. The products common to each endowment were gathered and harmonized after discussion with caregivers. Each sector has kept a stock of specific devices, called “out-of-stock”.

What has been achieved?

The installation took about 632 hours of HPP time. The allocations for each sector were respectively 68, 69 and 83 references, not including out-of-stock. The HPP’s work allowed reducing the common endowment from 220 to 134 products references. A satisfaction survey of PTI teams (doctors, nurses,…) after 4 months of practice showed a level of 78% of satisfaction. 1.3% of the responses concerned activities related the management of devices affected by production delay or stoppage and information on product changes to be unsatisfactory or moderately satisfactory. Every ITP teams now considers their presence essential, believes that it has improved relations with the pharmacy and management of stocks. A saving in nursing time was also noted.

What next?

The creation of this HPP position seems to satisfy all the ITP teams. A quantitative analysis of the benefits measuring the impact on care time, the amount of over-storage and the compliance indicators of the implantable medical device circuit will be carried out during 1 year, in order to assess the impact of the creation of HPP positions within the PTI.

Author(s)

PATRICIA ORTIZ FERNANDEZ, Alba Maria Martinez Soto, PILAR FERNANDEZ-VILLACAÑAS FERNANDEZ

Why was it done?

1.Reduce the stocks of drugs in the medicine cabinets of the hospitalization units (HU). 2. Adapt scheduled drugs dispensing to those of preparation and administration at the HU. 3. Reduce the number of returns of dispensed drugs, as the main indicator of improved efficiency.

What was done?

Optimize the drug distribution circuits within the hospital, adapting them to the changes produced in the organization to increase the quality and efficiency of the drug use process.

How was it done?

1. Constitute an improvement group (pharmacy service (PS), supervisors oh HU and nursing address.
2. Define and propose stock agreements by the PS
3. Call meetings to review the agreement and circuit of drug dispensing
4. Incorporation of agreements in the corporate program and implementation of the agreed circuit changes.
5. Publish the updated drug distribution circuit
6. Restructuring of medicine cabinets
7. Evaluation of indicators: a) Decrease types and amounts of drugs in HU. b) Decrease in drug returns of drugs to PS

What has been achieved?

A total of 6 meetings have been held, reaching the following agreements:
1. Mantain a reduced stock of drugs in the HU
2. Establishment of the medicine cabinets agreements for the 14 HU.
3. Limitation of request for medication by stock. Ant other request will be made individually for each patient.
4. Circuit changes:
a. Partial modification of the medication dispensing schedule in the unit dose dispensing system
b. Streamlining the comunication system between the pharmacy service and hospitalization units.
c. Dispatch of medication dispensed in patient transfers
d. Establishment of criteria for urgent requests
5. Written dissemination of the changes to all pharmacy and nursing staff

What next?

Quality indicators will be avaluated 6 months after implementation.
We hope to avoid ineficiencias derived from the existencce of double circuits and to optimaze the control and preservation of drugs in the HU
The establishes drugs is not static, modifications are posible.

Author(s)

Elena Bazzoni, Roberto Pane, Claudia Montanari, Giulia Rocca, Camilla Ercoli, Maurice Oriente De Ponzio, Thérèse Gregori, Simonetta Radici

Why was it done?

Piacenza is one of the most hardly hit cities in Italy during the first wave of COVID-19. Due to the severe impact that this pandemic had in the area, hospitals were saturated with patients with respiratory failure. We thus needed to rapidly set strategies that allowed a fast dismissal of patients from the hospital without interrupting their oxygen therapies or avoid their hospitalization in case of mild respiratory failure.

What was done?

Starting from COVID-19 pandemic, our pharmaceutical unit cooperated with medical doctors of the area to allow home-delivery of oxygen therapies and grant continuity between hospital and territory. We thus developed a structured system that allowed fast activation, efficient tracking, prompt variations, and dismissal of patients from oxygen therapies at their house.

How was it done?

Since February 2020, all the oxygen therapy prescriptions from the hospital and the territory converged to the pharmaceutical service. In collaboration with the pneumology unit, we set up a database collecting patient generalities who needed oxygen therapy to grant the proper follow-up during the pandemic. In April 2020 the database was shared also with medical doctors belonging to the newly formed Special Unit for Assistential Continuity (USCA). This team was in charge of visiting patients at their houses. In collaboration with USCA and the IT service, we developed a web-based system that allowed real-time communication between Pharmacy, USCA teams, and some hospital units granting the continuity between hospital and territory.

What has been achieved?

From the beginning of the pandemic, the pharmaceutical unit has handled more than 960 requests of oxygen therapies regarding more than 900 patients. Our database is updated with all of the patients granting the tracking of each one of them as well as the therapies assigned. Our system also allowed USCA to follow patients on the territory reducing the pressure on hospitals. In 2020, indeed, more than 75% of oxygen prescriptions were requested by hospital units while in 2021, 81% of them came from USCA and territorial units.

What next?

Our currents efforts aim to reduce procedural complexity to grant access to pharmacological therapies. This new web-based system represents, indeed, an versatile and key tool to reach our goal. We are currently extending its use to the whole hospital for oxygen therapies independently of the underlying pathologies. This will allow an easy and complete transfer of these therapies on the territory. Moreover, we are implementing the possibility to prescribe drug-based pharmacological therapies in an in-home context.

Why was it done?

Immunoglobulins are currently used both for the indications included in the SmPC and for other indications with different degrees of evidence and priority. Nonspecific immunoglobulins are blood products obtained by fractionation of plasma. During the Covid 19 pandemic there has been a decrease in donations and therefore a decrease in reserves in blood banks, which has generated a general shortage of immunoglobulins.

What was done?

Creation of a multidisciplinary advisory commission for the evaluation and optimization of the use of immunoglobulins in the current situation of shortage.

How was it done?

A multidisciplinary commission was created made up of a pharmacist, a hematologist, and other specialists involved in the immunoglobulin prescription circuit. Chronic treatments with nonspecific immunoglobulins active between April and June 2021 were evaluated, an immunoglobulin use guide was developed prioritizing those indications with grade of evidence Ia, Ib and IIa and urgency of type A or B(solid evidence and absence of alternatives with equal efficacy)for both chronic and acute treatments. In addition, an emergency stock was established for acute pathology

What has been achieved?

After the intervention, the following were included in the guide for the use of immunoglobulins as priority indications: primary immunodeficiencies, Kawasaki disease (Ia, A), Guillain Barré (Ib, B), Multifocal Motor Neuropathy(Ib, A), Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) )(Ia, A), Idiopathic Thrombocytopenic Purpura(ITP)(Ia, A),Secondary immunodeficiencies(Ib, A)with severe or recurrent infections, ineffective antimicrobial treatment, proven failure of specific antibodies and / or serum IgG level <4 gr / l. During the quarter prior to the creation of the commission, 31 patients were treated with immunoglobulins, 77.42% of whom were chronic; the most common indication was secondary immunodeficiency, 41.93%. Total immunoglobulin expenditure in this quarter (from April to June 2021) was 3,075g(mean: 99.2g / patient), with a cost of €15,925.98. While in the following trimester (post intervention)11 patients were treated, 72.73% being chronic, the most common indication was secondary immunodeficiency 36.36%. Total immunoglobulin expenditure in this quarter(from July to September 2021)was 660g (mean: 60g/patient), at a cost of €42,664.05

What next?

Carry out periodic control of active chronic treatments and assessment of the initiation of treatment according to the guidelines established by the Commission

Author(s)

LEONOR GOMEZ-SAYAGO, INMACULADA LOMARES MANZANO, LUCIA JIMENEZ PICHARDO

Why was it done?

Biosimilar medicines have demonstrated their bioequivalence with the original biologic and there is ample scientific evidence to support this.
Our Hospital had a degree of implementation of biosimilars of 8,16% (the lowest in its autonomous community), so it was decided to develop an intervention plan to increase the use of biosimilars and improve this indicator.

What was done?

Develop a plan to increase the use of biosimilar medicines in a tertiary hospital.

How was it done?

It was decided to intervene on these drugs that had commercialized biosimilar drugs: etanercept, adalimumab, trastuzumab, bevacizumab, enoxaparin, epoetin. For the introduction of biosimilars of etanercept and adalimumab, the medical records of all patients with these prescriptions were reviewed and all those that were prescribed by active ingredient and not by brand-name drug, were changed to a biosimilar medication after consensus with the patients. For the new prescriptions of these drugs and of enoxaparin, trastuzumab, and bevacizumab, a document was prepared supported by the medical direction of our Hospital that would start with biosimilar molecules. Regarding epoetin, in our hospital we had epoetin beta that does not have a biosimilar, so it was decided, agreeing with oncology and hematology and based on the evidence, to change the molecule to epoetin alfa with its biosimilar medicine.
The degree of introduction of biosimilars was measured with the formula: nº Definid daily dose of biosimilar drugs dispensed/nº Definid daily dose of biosimilar drugs dispensed+Definid daily dose of the original biologic *100.

What has been achieved?

Before the implementation of the protocol for the introduction of biosimilars, the degree of introduction was 8,16%, 3 months after implementation the result had reached 21,10% and at 6 months it was 30%. This represents an economic impact of 286.295,53 € per year in savings.

What next?

The implementation of protocols agreed with the prescribers for the introduction of biosimilars should be a common practice of the hospital pharmacists to contribute to the sustainability of the health system.

Author(s)

Louise Refsgaard, Linda Skovsted, Nina Bøggild

Why was it done?

The medical supply vending machines were implemented during 2021 as a way of direct-to-patient distribution of medicine with more flexibility. The aim was to offer 24-hour access to collect medicine at a location that suits the patient, e.g. close to the patient’s home.

What was done?

Medical supply vending machines were implemented in the Capital Region of Denmark. The vending machines allow patients to collect their medicine whenever and wherever it suits them. It is the patient’s healthcare professional that controls and orders the medicine. The hospital pharmacy staff consults the prescription and labels, dispenses and records the medicine and places it in the vending machine for collection.
Patient and staff satisfaction was surveyed.

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. Installing the machines was fast but a full implementation requires that the clinical staff rethink their practice and accept that dispensing is no longer their responsibility. This has been the biggest obstacle along with creating patient safe procedures.

What has been achieved?

7 medical supply vending machines were installed centrally in hospitals in the Capital Region of Denmark. The machines are now used to distribute medicine to some of the region’s outpatients.
The patient satisfaction survey showed that the patients are very satisfied with the vending machines: 100 % are either ‘highly satisfied’ (86 %) or ‘satisfied’ (14 %) with the new service, and 97 % would like to use it again. The staff was also satisfied with the new service.
Additionally, the quality of medicine dispensing is increased due to hospital pharmacy staff dispensing the medicine rather than nurses.

What next?

In order to offer flexibility to patients and increase the quality of dispensing of medicine, we aim to increase the number of patients that collect their medicine from the vending machines by using the current machines in their full capacity and installing more machines. We also aim to collaborate with Denmark’s other 4 regions, so that patients, who are treated outside their home region, can collect their medicine in a vending machine closer to their home.

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Author(s)

BERTA MONTERO-PASTOR, ELSA IZQUIERDO-GARCÍA, LORENA DE AGUSTÍN SIERRA, ISMAEL ESCOBAR RODRIGUEZ

Why was it done?

The unprecedented mass COVID-19 vaccination has highlighted the need to develop strategies that prioritize and optimize the use of resources. Strategies have been established at the national and community levels, however, each center must implement its own plan according to needs and capabilities for its target population.

What was done?

A Pharmacy Department (PD) vaccination plan including strategies to optimize human and material resources available to deal with mass COVID-19 vaccination.

How was it done?

In plan development, we considered the type of vaccines, storage requirements, the need for specific equipment and workflows, limited vaccine vial supply, and aspects related to staff in the PD.
A standard operating procedure (SOP) was developed for logistic management of vaccine orders, including an SOP for nursing staff if the shipment arrived outside the PD schedule.
For storage, specific space was provided considering the different storage requirements.
The doses corresponding to the vaccination of health professionals and patients from group 7 of the national vaccination strategy (onco-hematologic patients with active treatment, hemodialysis patients, primary immunodeficiencies, HIV -CD4<200cel/ml, Down Syndrome ≥40 years) were prepared centrally in the PD. For the general population, a centralized preparation in PD is not feasible. So, alternatively, PD developed a dispensing circuit and informative material for nursing staff for the correct dosage and traceability of vial batches. In all stages, the use of vials was optimized with strategies such as the selection of adequate packaging material, the grouping of patients, or the exchange of vials between vaccination centers.

What has been achieved?

We received 16230 vaccine vials from four different commercial brands. There have been no incidents related to the receipt and storage of vaccines.
A total of 9753 doses were made. In the whole elaboration process, we only wasted a vial on one occasion and a dose on another.
We dispensed 11911 vaccine vials to the general population. Of these, 13 vials were discarded due to errors in the preparation.

What next?

The development of a specific plan has made it possible to optimize the COVID-19 vaccination process in our hospital. The plan will be adapted and updated according to the updates of the national and community vaccination strategies.

Author(s)

Francesco Falbo, Oscar Martinazzoli, Agnese Bruni, Rosanna Lettieri, Simona Polito, Luisa Zampogna, Valentina Marini, Michela Mazzucchelli, Marcello Sottocorno

Why was it done?

The involvement of the pharmacist featured:
– Drug supply and storage
– Medical devices (MD) and personal protective equipment supply
– The creation of a catalog of required drugs
– Medication supply chain management and dispensing
– Management of medical gases
– Evaluation of the effectiveness and safety of drug therapy.

What was done?

As the COVID-19 epidemic spread, temporary critical care hospitals have been opened in order to attend the incoming burden of infected patients. In April 2020, one of the largest ever temporary healthcare structure was created in only 10 days. The ark hospital was opened for nearly 10 months and hospital pharmacists supported the effort for the pharmacy management.

How was it done?

The development of a catalog of required drugs has been accomplished using the consumption analysis on drugs and MD in March 2020 of the permanent hospital Covid unit. Thus, we created a dynamic catalog – constantly updated – consisting of 530 drugs and 345 medical devices. The medical staff members of the temporary hospital filled a special form for extra-catalog material. Running a cost-effectiveness analysis, the pharmacist managed to evaluate the purchase, rather than recommend a valid alternative from the material on the catalog.
The pharmacy warehouse was planned by dividing the MDs categories. Likewise, the drugs were stored according to their pharmaceutical form and their alphabetical order.

What has been achieved?

The materials requirements planning was achieved in 15 days, including medical supply ordering and the pharmacy warehouse organization. Pharmacists ensured the optimization of resources, the availability, safety and optimal use of medicines and MDs, as well as the monitoring of the adverse drug reactions (ADR). Hence, all patients received the appropriate pharmacotherapy. The pharmacist played a key role in the good functioning of the ark hospital in collaboration with all the medical team.

What next?

In conclusion, a new protocol and standard of care for managing health emergency will be the following and challenging step.

Author(s)

Alina Shramko, Veronika Haziahmetova

Why was it done?

Based on the results of the analysis, it is possible to answer the question whether it is advisable to spend financial resources, using the example of one healthcare facility; what steps should be taken to rationalize drug procurement; which drugs should be considered first of all for inclusion/exclusion from the procurement list.

What was done?

Currently, ABC/VEN analysis is one of the most effective pharmacoeconomical methods recommended by WHO for the use in the healthcare system. The use of pharmacoeconomic methods is carried out in accordance with the inherent effective use of drugs, and is carried out strictly in accordance with the principles of evidence-based medicine.

How was it done?

The ABC/VEN analysis was conducted based on data from the pharmacy of the LPI containing the costs of purchasing medicines during 2020. The VEN category was determined after a thorough review of the evidence available to us about the effectiveness, safety and cost of drugs.

What has been achieved?

The cost of drug provision to healthcare facilities in 2020 amounted to 62 943 951,38 rubles. The number of international generic name purchased and used was 355. About 35% of the funds were used for a group of vital medicines. The cost of the necessary medicines amounted to 43% of the funds – this corresponds to WHO recommendations.
In accordance with the ATX-classification, drugs affecting blood formation and blood are in the lead in terms of the volume of costs – 40.9% of all costs.
The drug is enoxaparin sodium, the leader in terms of costs in 2020. It is a direct anticoagulant (low molecular weight heparins with a molecular weight about 4500 daltons), which has an antithrombotic effect (2.38% of the total budget).
Also, the top ten leaders in terms of costs included saline sodium chloride solution – 6.1% of the annual budget, which probably indicates irrational excessive use of infusion therapy.

What next?

The application of pharmacoeconomical methods and principles of evidence-based medicine allowed us to assess the feasibility of drug procurement and serves to rationalize the use of medicines.

Author(s)

Francisco José Toja Camba, Carmen Lopez Doldan, Laura Casado Vazquez, Aron Misa García, Pilar Rodriguez Rodriguez, Maria Elena Gonzalez Pereira

Why was it done?

Hospital Pharmacy must develop new models of pharmaceutical care (PC), improving patients quality of life and enhancing care services. One type of these strategies are non face-to-face PC, such as telepharmacy and home delivery, achieving a new integrated and patient-centered healthcare model.
COVID-19 health crisis and the need to ensure the delivery of medicines to susceptible people and guarantee home isolation, has motivated a paradigm shift in health care.

What was done?

• Guarantee quality of care in pharmacy consultations (PCC) due to COVID-19 pandemic.
• Implantation of telepharmacy and home delivery of hospital medication.

How was it done?

Three different circuits were designed:
1. Single healthcare act of face-to-face visits in PCC coinciding with other medical appointments. Prior appointment, non-contact consultation agendas and extension of service hours were reinforced.
2. Informed home delivery of hospital medication at home, after prior teleconsultation: pharmacotherapeutic follow-up and request for informed consent. Management and preparation of packages, including motivational messages, to humanize the process. Distribution logistics model based on defined routes and schedules. The confidentiality, security and traceability of the entire process was certified.
3. Open and permanent communication channel between patient and pharmacist that enabled individualized PC.
Patients with mobility problems, home isolation or chronic processes with a higher risk of COVID-19 infection were prioritized.

What has been achieved?

From March to May 2020, 1,938 pharmacotherapeutic follow-up teleconsultations were carried out (291 patients had been attended in person due to having another medical appointment or due to personal preferences). Medication was home delivered to a total of 1,647 patients. A total of 120 routes were made between the four established routes (average of 15 shipments per working day). Percentage of satisfaction expressed by the patients was 95%.

Main limitations were:
1. Operational challenge: changes in workflows, organization of schedules and work times, increase in telephone lines, route management in a very dispersed geographic area, technology gap (mean age ≥ 60 years) …
2. Human resources.
3. Medication shipping cost.

What next?

• Development of new management tools: telepharmacy and home delivery and pharmacotherapeutic follow-up of patients guarantee continuity of non-face-to-face PC.
• We must support initiatives that certify efficient and safe care as well as humanitarian care.