Author(s)

Andreia Fernandes, Mafalda Brito, Tatiana Mendes, Armando Alcobia

Why was it done?

Many patients had their health care needs compromised due to accessibility issues. They could not come to the PS because of the mandatory confinement, prophylactic isolation and medical indication.

What was done?

In the context of the Covid 19 pandemic, between April and June 2020, pharmaceutical Services (PS) instituted several alternatives delivery processes that guaranteed patients’ access to the medication, usually provided on the PS.

How was it done?

Pre-existing accessibility projects to deliver medication in community and hospital pharmacies have been adopted. In order to respond to all requests, new ways and protocols of medication distribution/delivery, like city hall transport, courier services and humanitarian aid (for example, motards), were created. For all deliveries outside PS, pharmaceutical telephone follow-up (teleconsultation) was realized.

What has been achieved?

7448 medication dispensations were registered, of which 80.7% were realized in person in the hospital PS (n = 6679). In the homolog period, 10621 dispensations were registered, of which 95.9% were in person (n = 10183).
438 deliveries were sent to community pharmacies, a total of 219 patients (54.3% female, maximum age 100, minimum 9 years). 41% increase compared to 2019. 198 shipments were realized to different hospitals and others healthcare units, corresponding to 120 patients (56 female, maximum age 85, minimum 8 years). 25% increase over the previous year.
New alternatives: City Hall 66 deliveries for 62 patients (58.0% female, minimum age 18, maximum 97 years), other deliveries 35 users (50.7% male, maximum age 94 and minimum age 10 years).

What next?

The Covid-19 pandemic triggered a need for adaptive evolution of pre-existing accessibility projects, but also the creation of new protocols and alternative means to respond to all patients who may have their healthcare compromised due to accessibility issues. The positive points were the implementation speed, maintenance of adherence to therapy (teleconsultation), traceability, reduced costs, synergy between patients/associations/pharmacists/healthcare professionals and a high degree of satisfaction. In spite of some limitations (dependent on volunteering; need for human resources; structured communication) we aspire to improve the new approaches of medication delivery on a nation level.

Author(s)

Francesca Venturini, Olivia Basadonna, Roberta Rampazzo, Girolama Iadicicco, Giovanna Scroccaro

Why was it done?

Remdesivir is the first authorized medicine by the European Medicine Agency (EMA) for SARS-COV2 treatment. In the first place, remdesivir was supplied exclusively in the context of the Emergency Support Instrument by the European Committee. A limited number of treatments were available to each member state, before Veklury marketing. Also after the national procurement process, through the joint procurement agreement by the EU, the number of vials was limited.

What was done?

A controlled regional distribution of remdesivir (Veklury) was implemented by the Veneto Region, Italy, through the hospital pharmacies network, using a regional distribution center located at the hospital pharmacy of the Padova University hospital.

How was it done?

In the first shortage phase, the Italian Medicine Agency (AIFA) defined the selection criteria for the use of remdesivir, based on clinical trials evidence. A centralized authorization procedure was implemented: each hospital was requested to send daily individual prescriptions through the local hospital pharmacy, to a dedicated AIFA email address
After AIFA authorization, the Ministry of Health forwarded the authorizations to the regional distribution center, for drug distribution.
A map of hospital pharmacies references (e.g., pharmacist name, hospital postal address, mobile phone, presence of the pharmacist on duty, etc) was created, in order to quickly contact them for the distribution of the authorized therapies.
The regional distribution center took charge of the authorized therapies and provided a personalized distribution to all the hospitals in the region. Each day the Ministry of Health warehouse replaced the stock of the regional distribution center.

What has been achieved?

in a 3-week period, the regional distribution center dispensed therapies for 87 patients to 17 hospitals in the region. In two cases a zero stock ck of vials was managed with the reallocation of experimental drugs left by closed clinical trials and compassionate use programs, both authorized by AIFA and the manufacturer.

What next?

in the second phase of the shortage, single patient prescriptions will be validated by local hospital pharmacists in a national electronic registry. On a by-weekly basis, the infectious disease regional network will audit treated cases, to verify inclusion criteria and discuss future approaches. A centralized distribution will be maintained, allowing a small stock in each hospital for emergency use.

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Author(s)

Lierni Goitia Barrenetxea, Natalia Toledo Noda, Moisés Pérez León, Victoria Morales León

Why was it done?

Lopinavir/ritonavir is a HIV-1 and HIV-2 proteases inhibitor indicated for HIV. It was used in patients with a positive SARS-CoV-2 test after being recommended by the Chinese health authorities. The hospital protocol guideline was: 400/100mg every 12 hours orally. It was presented in both tablets and oral solution, which was reserved for patients intubated in the ICU and those who were not able to take tablets.

What was done?

Optimizing the use of lopinavir/ritonavir solution during the state of sanitary emergency.

How was it done?

Descriptive study of resources optimization for lopinavir/ritonavir and actions carried out to ensure the availability of the antiviral in intubated SARS-CoV-2 positive patients. Preparation and stability data were obtained from official sources (Spanish Agency for Medicines and Health Products) and from the Spanish Society of Hospital Pharmacy.

What has been achieved?

The Pharmacy Service designed a protocol to repackage lopinavir/ritonavir 80/20mg/mL solution in syringes containing the exact amount for a single dose (400/100mg in 5ml), for single use. The solution is formulated on an alcoholic basis and there is an interaction with the polyurethane nasogastric tube because the polyurethane absorbs alcohol causing the catheter to swell and deteriorate, which is why, other services were notified to use polyvinyl chloride catheters or silicone. Likewise, the syringes used to repackage the solution were exclusive for oral administration used in pediatrics, with the aim of reducing medication administration errors, since it is not possible to connect parenteral injection needles with them. These measures were intended to make the dispensing system as efficient as possible, as once the drug entered a unit with patients with a positive test, it was contaminated, therefore it could not be reused. Additionally, the fact that the hospital is located on an island made it even more difficult to acquire the medicine, given the supply problems nationwide, the great restriction of air and maritime traffic and loan limitations from other hospitals.

What next?

The measures adopted managed to ensure the availability of lopinavir/ritonavir solution in all admitted patients, optimizing the scarce availability of a solution medication whose presentation is formulated in multidose containers. By adding the use of syringes for exclusive oral use, administration errors were prevented.

Pdf

Author(s)

Rosalia Fernández-Caballero, Virginia Collados Arroyo, Clara Herranz Muñoz, Araceli Henares López

Why was it done?

Every month, an average of 700 patients receive pharmaceutical care in the outpatient consultation (OC) of our first-level hospital. Given the mobility restriction measures applied by the spanish government during the pandemic, access to this consultation was difficult for some patients. The aim of this program is to ensure the access to medication for all patients and prevent them and professionals to virus exposure. Telepharmacy program consists of providing pharmaceutical care based on available means of communication and access to medication through home drug delivery.

What was done?

During the COVID-19 pandemic, we designed and implemented a telepharmacy programm to ensure access to medication for all patients.

How was it done?

Once weekly, the pharmacist contacted the listed patients during the following week in OC by telephone or via the hospital’s electronic platform, to offer the possibility of participating in the program. During teleconsultation, pharmacist provided the same attention as in face-to face consultation: administrative situation of the patient, adequate medical follow-up, assessment of adherence, review of interactions and adverse events and treatment changes. Moreover, we e-mailed the patient’s consent for home drug delivery by and external company. In case the patient didn’t have a web mail, we requested verbal consent. Once a week, one pharmacy technician prepared the medication and the selected company performed the home delivery in guaranteed storage conditions. To minimize the burden of work, the medication was sent for two months per patient. Oncohematological patients, who came to their doctor’s appointment every month, were excluded from this program.

What has been achieved?

Between March 20 and October 9, we have included 595 patients in this program and conducted 1190 teleconsultations and 872 home drug deliveries with a great satisfaction of outpatients.

What next?

Our next step is to improve the web system for sending alerts through our electronic platform to automate the home delivery process and thereby to reduce the logistic burden of the pharmacist and to increase the pharmaceutical care given to patients.

Pdf

Author(s)

MARINA RODRÍGUEZ MARÍN, HILARIO MARTÍNEZ BARROS, MARÍA DEL ROSARIO PINTOR RECUENCO, BEATRIZ MONTERO LLORENTE, ANA MARÍA ÁLVAREZ DÍAZ

Why was it done?

It was done in order to optimize opioids stock to meet the needs of COVID-19 patients and protocolize the correct quarantine without modifying the computerized registration in the 39 ADS.

What was done?

A procedure was implemented to optimize the stock and manage the quarantine of opioids in Automatic Dispensing Systems (ADS) during and after their use in hospital units hosting COVID patients.

How was it done?

As hospitalization units were being adapted to host COVID-19 patients, opioids stock had to be modified to meet their new demands. Reversely, when hospitalization units were recovered to host their usual type of patient, the opioids had to be replaced and quarantined for ten days, according to our Preventive Medicine Unit. All these movements were recorded.
We followed this process:
1. Physical and computerized unloading of opioids without dispensing in recent months and emptying of the returned drawer (storage space for opioids withdrawn from the ADS which were not used).
2. Relocation to hospitalization units hosting COVID-19 patients,
3. Replacement of all (minidrawers) where opioids were kept with clean ones
4. Quarantine in the Pharmacy Service, for the drugs unloaded which were unable to be immediately relocated.
5. Cleaning and sanitizing of the removed minidrawers from COVID-19 hospitalization units’ ADS to be used in the next conversion.

What has been achieved?

29 ADS of the 39 available in the hospital were optimized.
Given the decreased in COVID-19 admissions during May, the hospital made a schedule to return to normality which allowed to leave 5 ADS in quarantine without the need to unload or replace any drug,. The other 24 ADS had to be cleaned and disinfected,. It led to the physical unloading of 182 specialties (a total of 1,519 units), the physical and computerized unloading of 124 specialties (850 units) and the emptying of the returned drawers (18 specialties and 20 units). 504 minidrawers were replaced by other cleaned and disinfected ones and 298 specialties (2,080 units) were replaced.

What next?

Enhancing our protocol to allow us to spend more time with the patients in Covid’s further waives.

Pdf

Author(s)

Daniele Leonardi Vinci, Adriano Meccio , Alessio Provenzani, Piera Polidori

Why was it done?

The COVID 19 pandemic unprecedently challenged National Health Services to assure adequate patient care, despite a constantly escalating drugs demand. This complex situation requires appropriate planning to avoid misleading estimations, which would have consequences on patients and overall resources available.

What was done?

We created a tool to perform a timely estimation of the drug needs to treat the COVID-patients based on epidemiological forecasting.

How was it done?

The tool’s epidemiological forecasting was based on a compartmental model in which the population is divided into three compartments (Susceptible-Infectious-Removed, SIR), and transmission parameters are specified to define the rate at which persons move between stages. The appropriate data entry was guaranteed by the creation of a form in which users can enter information regarding: The population considered, the R0 calculation, the number of already known infected cases, the application of Non-Pharmaceutical Interventions and the number of hospital beds. The drugs need for the forecasted patients was calculated according to a list of critical care drugs compiled consulting previous published scientific works, national and international guidelines. The list includes 51 drugs belonging to different therapeutic group, such as: antiarrhythmics, antibiotics, antipyretics, antivirals, heparins, IV-fluids, local anesthetics, neuromuscular blockade agents, sedative agents and vasopressors. For each drug it was estimated the percentage average ICU uptake for therapeutic group and active principle.

What has been achieved?

A tool consisting of an excel template, that, based on the information inserted, automatically calculate the number of patients classified by the intensity of care (hospitalized not-ICU, Hospitalized ICU, ventilated, intubated or with shock) and creates a table that includes, for each drug to be used, the following information: therapeutic group, active principle, dosage considered, pharmaceutical form, total dosage for patients considered and total quantity of unit doses for patients considered. The tool is also made adaptable to different clinical situations, through the possibility of editing the assumptions adopted regarding the epidemiological and therapeutical parameters or the inclusion of new items in the drugs list.

What next?

Our tool represents an opportunity for the immediate and efficient estimation of the drugs necessary to assist the COVID19 patients during emergency scenarios. It will be periodically updated as new evidences will be available.

Pdf

Author(s)

Helle Brauner

Why was it done?

There was a need for improved planning and preparing processes, as when it comes to price negotiations and estimates on financial burden and strategic procurement.

What was done?

Amgros, a part of the Danish health care system, has secured the supply of medicines and hearing aids to public hospitals and hearing clinics across Denmark for 30 years. This is done through efficient procurement and tendering procedures, creating economies of scale and savings.

In addition to this, in January 2017, Amgros launched its own Horizon Scanning unit. Now, the Danish Horizon Scanning system provides the health care system with an overview of medicines, indications and extensions e.g. pharmaceutical forms expected to be entering the Danish market within the next 2-3 years.

How was it done?

In 2016, it was decided to establish an Horizon Scanning system in Denmark. Then, input from internal and external stakerholders regarding their needs and expectations were gathered.

The outputs from the Horizon scanning unit consist of an overview of medicines about to reach the Danish market, as well as estimates of costs for new, expensive medicines and possible savings, for example if there are cheaper biosimilar drugs on the market. We also assess potential patient population and location of treatment. This is done in close cooperation with several Danish clinicians.

Sources for verifying and validating the data inputs are primarily EMA, complemented with commercial databases and a niche group of other sources. Data is gathered in a database.

What has been achieved?

The outputs enable our stakeholders to better plan the introduction of new medicines, to secure more cost-effective health solutions for everyone and to achieve more health for money in the Danish hospital setting.

Danish Regions, the interest organization for the health care regions, use the estimates in their annual negotiations with the Government on finances and the individual regions use them in their own budgets.

The predictability this system brings to Denmark is key in a future with more rare diseases, treatments and advanced pricing.

What next?

The Horizon scanning function is continuously being developed to meet the needs of our stakeholders, as we want to enable them in providing health care to the Danish citizens.

Pdf

Author(s)

Rebeca Iglesias-Barreira, Emilio Rubén Pego-Pérez, Carlos Sandoval-Aquino, Cristina López-Pardo y Pardo, Maria Jesús Rodríguez-Gay

Why was it done?

To guarantee workers safety as well as optimize the use of PPE in the hospital.

What was done?

To develop a protocol for placement and removal of personal protective equipment (PPE), established for contact with possible or confirmed coronavirus SARS-CoV-2 infected patients, taking into account the medical devices (MD) available during the pandemic. Alternatives and strategies were also proposed for resources optimization. Final protocol resulted from a multidisciplinary team work (Hospital Pharmacy Service team and Emergency Service workers). It was finally revised and approved by the Medical and Quality Direction.

How was it done?

1)A systematic bibliographic review was made, for articles selection on the placement / removal of PPE. Technical specifications of the available MD and the sanitary recommendations of the competent organitations were reviewed.
2)Establishment of PPE components, and the order of placement and removal:
a. PPE placement:1-Wash hands (WH).2-Place shims.3-WH.4-Put on the first pair of gloves.5-Put on FFP2 mask.6-Wear waterproof protective overalls from the feet.7-Place garbage bags on feet and adjust them on legs.8-Wash gloves with a hydroalcoholic solution (HS).9-Put on second pair of gloves.10-Put on a standard/reinforced surgical gown.11-Wash HS.12-Put on surgical mask.13-Put on disposable gown.14-Put on third pair of gloves.15-Put on face protection screen. 16-Put on surgical cap and fit it over a face shield.
b. PPE removal: a) Before leaving the isolation room: 1-Remove and discard bags from both feet.2-Remove and discard disposable gown.3-Remove and discard the outermost gloves. b) Outside the isolation room: 1-Wash HS.2-Remove surgical cap and screen (reserve screen).3-Remove and discard surgical mask.4-Wash HS.5-Remove the standard/reinforced surgical gown and reserve it.6-Remove second pair of gloves.7-Wash HS.c) Before entering the clean area:1-Remove shoes.2-Remove third pair of gloves.d)Go to the clean area:1-Disinfect footwear.2-Wash HS.3-Remove monkey and if necessary reserve it. 4-Wash HS.5-Remove FFP2 mask and reserve it if necessary.6-WH.
c. A team member read and check all steps carried out during the all steps procedure.

What has been achieved?

The protocol was followed by 54 (100%) workers. Since its implantation, on March 16 th, only the 3,7% (n=2) of workers were infected by SARS-CoV-2.

What next?

The protocol is under constant revision and modification to adapt it to the available MD in every moment.

Pdf

Author(s)

Daniele Leonardi Vinci, Enrica Di Martino, Rosario Giammona, Piera Polidori

Why was it done?

The 2018 Medicines Shortages Survey conducted by EAHP showed that 91% of responding pharmacists had experienced problems sourcing medicines, therefore it is important to use tools that identify early the shortage risk associated with each drug included in a hospital formulary in order to adopt appropriate countermeasures.

What was done?

We create an informatic HVA Tool (HVAT) to assess the risk associated with medicine shortage.

How was it done?

The HVAT created consists of an Excel spreadsheet subdivided into three macro areas: probability that the shortage will occur based on shortage in the last 2 years, magnitude factors which increase the risk of shortage, and mitigation factors which reduce it. A score was assigned to each item in each macro area. The score of the probability was: 1=no previous deficiency; 1.5=one deficiency; 2=two or more deficiencies. Magnitude was divided into: relevance of active substance (AS) (1= not life-saving and not High Risk Medicines (HRM); 2=not life-saving but HRM; 3=life-saving); budget impact (0=no alternative drug; 1=alternative drug costs equal to or less than the deficient one; 2=cost of the alternative drug higher than the deficient one but sustainable for all patients; 3=cost not sustainable for all patients); percentage of patients treated with the drug (1=less than 20%; 2=from 20% to 50%; 3=more than 50%). Mitigation factors were: therapeutic alternative (1=same AS and same route; 1.5=same AS and different route; 2=different AS and route not intravenous (IV); 2.5=different AS and route IV; 3=no alternative drug); stock available (1=for a month of autonomy; 2= autonomy between 1 week and one month; 3=autonomy less than 1 week); availability of the drug (1=drug available in EU; 2=drug available exclusively extra-EU; 3=drug not available).

What has been achieved?

The HVAT obtained allows us to calculate the value of the risk multiplying P by S, where P is the percentage of probability (value of probability obtained/2) and S is percentage of severity [(sum of values of magnitude obtained + sum of values of mitigation obtained)/18]. Based on the score obtained, drugs are classified as: low (60%) risk of shortage.

What next?

We will implement the HVAT in our hospital in order to reduce the impact of shortages.

Author(s)

TRISTAN TERNEL, MELINDA PLACE, BERENICE GILLOTEAU, ELODIE DECHAMBENOIT, EMELINE DEVOS, FATEN ABOU-DAHER, ANAELLE DECOENE, THOMAS QUERUAU LAMERIE, FREDERIQUE DANICOURT

Why was it done?

The main purpose of developing this tool is the need to provide centralised product parameters through a unique summary screen that permits a regular monitoring of inventory, enabling us to identify the glitches before things get out of control, resolve issues the soonest to improve the stock control system (order threshold, market), maintaining compliance and documenting usage to prevent sudden shortages, in a harmonised way in order to reduce the time spent to order.

What was done?

Development of a dynamic stock management tool plugged into a computerised model (Excel©), to integrate all data needed for a stock forecast in terms of specialties, providers, therapeutic classes, last order date, supply disruptions, market, restocking time, turnover, stock, orders, security threshold, average daily consumption, average time of supply, and delivery estimated time for all pharmaceutical products in hospital.

How was it done?

It’s important to know how much you have from each product, and each dosage of the same product, through a dynamic database that’s collecting all data (product code and average daily consumption) and highlighting the order quantity threshold. This reliable inventory is updated on a daily basis with data extracted from our economic and financial management coupled with Business Object©. Using specific formulas and filters, and referring to the decision flowchart, such data allow adjusting and optimising our stock management in real time.

What has been achieved?

First, this tool has allowed us to gather all required data and, subsequently, reduced the need to another application (such as NEWAC© and MAGH2©). Second, it has allowed us to understand the mechanism of order suggestions by displaying characteristics of some sectors (such as expensive products and chemotherapy). Moreover, it improved the management of supply disruptions by showing the solution of each disrupted product in a summary table, which results in significant time saving along the drug supply chain.

What next?

An organised supply chain, a fast response to overcome and handle sudden supply shortages, as well as a huge time saving are the main reasons to rely on this efficient system, which lead to an optimised and secure patient care. Moreover, it fits any computer software, and its application is very friendly to be used in every hospital pharmacy.