The electronic health record (EHR) includes all of the documents relating to healthcare processes for each patient, identifying doctors and other professionals who have participated in their care in order to obtain the maximum possible integration of clinical documentation. The main purpose is to provide healthcare, recording all data related to medical judgments, allowing accurate and updated knowledge of the patient's health status.
Purpose
To analyse anthropometric data required for clinical monitoring of the patient and establishment of drug doses, as well as influencing the calculation of clinical values (renal clearance, BMI or body surface).
Material and methods
This was a cross sectional study in which all patients admitted to the hospital in a day were checked to see if they had their weight recorded in the EHR. We also checked if they were receiving drugs where it is recommended that doses are adjusted depending on weight.
Results
Of 481 patients admitted in a day to our hospital, 112 did not have their weight recorded (23.28%). Of these, 70.6% had treatments which required dose adjustment based on weight, such as enoxaparin or other antibiotics. Services with the highest percentage of weight recorded in the EHR were onco-haematology (96.3%), general surgery and digestive (92.59%), internal medicine (95%) and paediatrics (92.31%). Geriatrics had the least records of the weight of their patients (31.82%). It is particularly important in the geriatric population to record weight, to detect possible losses of unintentional or involuntary weight, and assess states of malnutrition. Onco-haematology had the highest recordings of patients' weight as most chemotherapy treatments require dose adjustments depending on weight, in addition to the software used for prescription and validation of these treatments, which also requires that weight is indicated.
Conclusion
The hospital has established a protocol for when a patient is admitted to hospital that nursing staff must collect weight and size when performing the physical examination. It is true that the patient's circumstances may hinder assessment of weight, especially in elderly populations, but this is not usual. Many drugs are adjusted depending on weight, so that should affect the performance of a complete physical examination, allowing the clinician to undertake good prescription and validation.
References and/or acknowledgements
Law 41/2002, 14 de noviembre (Spain). Decreto 38/2012, 13 de marzo. No conflict of interest
The unit dose system of medication distribution (UDDS) is a pharmacy coordinated method of dispensing and controlling medications in organised healthcare settings. In our hospital, medications contained in single unit packages are delivered during the morning for a 24 h period. However, after delivery, many drugs are requested throughout the day for different reasons. Medication dispensed in this way is more susceptible to medication errors than those included at UDDS.
Purpose
To assess drug requests (out of UDDS) from clinical units, identify the reason for the same and try to improve the process to reduce their numbers.
Material and methods
Retrospective descriptive study over a 2 month period in which request forms from various clinical units (traumatology, rheumatology and pneumology) were analysed, quantified and classified into 7 subgroups.
Results
During the study period, 605 requests for drugs were analysed and we observed the following distribution: 28%: drugs not prescribed. 21%: drugs that theoretically were distributed at UDDS. 18%: changes in treatment and new hospitalised patients. 15%: drugs not included in the hospital pharmacotherapeutic guide. 12%: drugs that are not distributed at UDDS for different reasons (multidose vials, drugs that must be given only in some situations like pain or insomnia). 3%: drugs for an erroneous route of administration. 3%: drugs that were not distributed at UDSS for different errors (human error, computer error).
Conclusion
55% of drug requests were not justified, with a high percentage of drugs that were notprescribed, which is often caused by verbal orders from doctors. 45% of drug requests were justified, with a high percentage of new hospitalised patients and changes in treatment. To improve the drug distribution chain and patient safety, we have decided to implement electronic medication request forms through electronic medical order. In this way, we can reduce dispensations of drugs not prescribed and ensure safe and correct distribution for new hospitalised patients and changes in treatment. According to this study, this would reduce by approximately 55% the number of dispensations out of UDDS.
References and/or Acknowledgements
We would like to thank all members of the Department of Pharmacy for their effort and patience during the implementation of this study. No conflict of interest.
Acquired haemophilia A is a coagulation disorder in which antibodies against factor VIII are produced, interfering with its activity and leading to potentially severe bleeding. Among numerous causes, cancer is a prevailing one. First-line haemostatic treatment until inhibitor eradication consists of bypass agents, including recombinant factor VII activated (rFVIIa) or activated prothrombin complex concentrates (aPCC).
Aim and Objectives
We present the case of a 70-year-old male patient diagnosed with metastatic prostate cancer who went to the emergency department of a tertiary referral hospital due to an acute-onset extensive hematoma on the right thigh, with neither personal nor family history of haemophilia.
Material and Methods
The patient was diagnosed with paraneoplasic acquired haemophilia. Therefore, immunosuppressive (methylprednisolone + cyclophosphamide) and haemostatic treatment (rFVIIa at 5 mg every 8h) was initiated. 9 days in, off-label use of emicizumab was requested, intended to guarantee a haemostatic level that would allow outpatient management. Emicizumab was administered subcutaneously at 3 mg/kg weekly over 4 weeks and then fortnightly over 16 weeks between January 13th and May 25th, 2022. Haemostatic was monitored daily during hospitalisation and weekly after discharge through determination of inhibitor activity (Bethesda Units, UB) and FVIII activity (bovine based Chromogenic Factor VIII assay, UI) in blood samples.
Results
The patient was successfully treated until the resolution of bleeding and normalised FVIII levels. Over the treatment with emicizumab as the only haemostatic agent (107 days), 8 subcutaneous injections were administered (cost: €51,255.2). Having used rFVIIa (5 mg every 12 h) would have entailed 214 intravenous infusions, with a direct cost of €618,301.64. Thus, emicizumab treatment meant direct cost saving of €567,046.44. Moreover, contributing factors to overheads as prolonged hospital stay, expenditure on consumables or staffing should be taken into account. Also risk of vascular access complications and quality of life must be considered.
Conclusion and Relevance
Emicizumab has been a safe and cost-effective alternative to rFVIIa in haemorrhage prophylaxis, reducing direct costs by more than 10 times and allowed outpatient management. Self-administration at home represents a major improvement in acquired haemophilia A quality of life. Hospital pharmacy and haematology must collaborate to achieve a rational use of resources and an improvement in quality of life.
Seven angiotensin receptor blocker(ARB) have been marketed, making it a therapeutic group capable of therapeutic exchange at the hospital. Losartan,irbesartan,candesartan and valsartan are available in the 'Hospital's Pharmacotherapeutic Guide(HPG) of our centre. Losartan is the ARB of choice for therapeutic exchanges based on efficiency criteria.
Purpose
The aim of this study is to analyse the effectiveness of ARB in hospitalised patients as a function of the ARB prescribed at admission.
Material and methods
A cross-sectional study was conducted in September 2017. All patients admitted to units with pharmaceutical validation were selected for treatment with any ARB available in the HPG and retrospectively. ARB home prescriptions were assessed, at admission, systolic blood pressure(SBP) and diastolic blood pressure (DBP) throughout the stay if it was <10 days or for a maximum of 10 days if it was higher and prescribed diet. It was defined as hypertension if SBP >139 if the age was <80 years or >149 if the age >80 years and/or if DBP >89. It was defined as hypotension if SBP <90 and/or if the DSP<60.
Results
We selected 48 patients, 18% of all patients admitted. Eight patients had no ARB prescribed at home. Twenty per cent (n=8) were >80 years: 10% (n=4) were diagnosed on entry of cardiovascular and ischaemic pathologies. The median stay was 12. 5±13. 5 days. The diet was 67% unsalted. A mean of blood pressure records was obtained of 14. 5±7. 4 (2/patient/day). The efficacy data are shown in the following table:
Conclusion
The most frequent alteration was hyperSBP. In the group of patients that maintained the same treatment prior to admission, there was a tendency to hyperSBP and hyperDBP, whereas hypotension was more frequent in the group where treatment was modified. These data suggest that therapeutic exchanges have no impact on the effectiveness of ARB. No conflict of interest
Opioids are safe and effective drugs that improve the quality of life of patients with chronic pain. However, they require close monitoring and appropriate training. Pain specialists consider that pain often has a mixed origin that requires prescription aids for the treatment of neuropathic pain.
Purpose
To analyse the adequacy of the recommendations for the treatment of chronic pain with opioid drugs in a tertiary care hospital.
Material and methods
This was a prospective study identifying prescriptions of opioid drugs (transdermal fentanyl, delayed release morphine and delayed release oxycodone) in patients hospitalised for 2 months using the electronic health record. We collected requirements for adjuvant drugs for the treatment of neuropathic pain, laxatives and rescue analgesia, and being following or not by the unit pain (UP).
Results
79 patients were prescribed any of the opioids studied, 38 men, with a mean age of 67.7 years, and 41 women, with a mean of 64.4 years. Distribution of patients by services was: oncology and haematology (25), internal medicine (13), general and digestive surgery (15), palliative care unit (6), geriatrics (4), pneumology (4) and other services (12). 47% patients were treated with transdermal fentanyl, 34% with oral morphine and 19% with oxycodone tablets. 23% of patients were monitored by UP. Prescription of transdermal fentanyl in patients followed by UP was only 21.6%. The most frequently prescribed drug for rescue was morphine (56%). 100% of patients followed by the UP had rescue analgesia, compared with 69% in the group without monitoring. 29% had prescribed treatment for neuropathic pain, 52% with pregabalin. In those followed by UP, prescription of an adjuvant for neuropathic pain occurred in 67%. It should be noted that 57% of patients treated with gabapentin needed the an adjuvant, versus 33% with pregabalin. 70% had a laxative prescribed, with little difference whether or not patients were followed-up by UP (72% vs 69%).
Conclusion
Pharmaceutical validation should be undertaken with these types of high risk drugs, so that prescription of analgesia rescue as well as prescribing laxatives can be recommended. Likewise, prescription of transdermal fentanyl should follow a protocol when favoured over oral and lower cost opioids.
References and/or acknowledgements
Dtsch Arztebl Int2016;113:616–25. Med J Aust 2016;205:334. No conflict of interest
Diabetes is a chronic pathology of high prevalence and a large number of associated comorbidities that have an impact on patients' quality of life. In the hospital environment, poor insulin adherence may lead to episodes of hyperglycaemia or severe hypoglycaemia, increasing long-term complications, as well as morbidity and mortality.
Purpose
To evaluate the clinical results obtained after the implantation of the insulinisation protocol in non-critical patients in our hospital. This protocol recommends the suspension of oral antidiabetic drugs (OADs) at admission, and if blood glucose >150 mg/dl, baseline insulin control is recommended along with control of preprandial glycaemias by administering rapid-acting insulin.
Material and methods
On 25 November 2015, a cross-sectional study (submitted to the Ethical Committee for Clinical Research) was carried out. In this study, all patients diagnosed with diabetes who were hospitalised and who had undergone validation of pharmacological treatment were located. The Electronic Clinical History (SELENE®) and the Pharmacy Service Managing Software (FARMATOOLS®) were used for the location and collection of clinical data.
Results
A total of 132 patients were evaluated. Sixty-four per cent and 36% of them were males and females respectively, with an average age of 69 years (range 29–93) and an average weight of 80 kg at admission. Fifty per cent of patients' weight was not registered and this is a vital fact for the evaluation of the patients' nutritional status and the calculation of the dose of insulin. Ninety per cent of patients had type-2 diabetes and 3% of them were diagnosed during their hospital admission. 46.4% of patients were treated with OADs in monotherapy, 15.2% with OADs plus insulin and 10.4% under a basal-bolus pattern. The overall compliance rate of the treatment to the basal-bolus pattern was very low (32%). These results are in line with the rest of the studies carried out in hospitalised diabetic patients.
Conclusion
In spite of gaining better glycaemic control with the basal-bolus regimen, the adherence to it was low. In the future, the suspension of the OADs, or their change to insulin after admission, will be a difficult target that we have to reach.
References and/or Acknowledgements
I would like to express my very great appreciation to the staff of the service. No conflict of interest
Up until 2014, basiliximab was used in our hospital as an off-label prescription for hepatic transplantation in patients for whom starting tacrolimus had to be delayed because of their baseline characteristics. Dosage is two 20 mg perfusions (days 0 and +4 after transplantation). The second dose could be skipped if the patient has stable renal function. From 2014 onwards, all patients undergoing transplantation received the first dose in order to delay beginning tacrolimus and to reduce morbidity and hospitalisation time.
Purpose
Clinical and economic assessment after the protocol change.
Material and methods
Retrospective analysis of liver transplanted patients in 2013 vs. 2014 (new protocol), registering: age, sex, diagnosis, creatinine on ICU and hospital discharge, ICU stay, global stay, number of basiliximab doses administered, day beginning tacrolimus treatment after transplantation, and global and per patient economic cost.
Results
Beginning tacrolimus was always day +1 when basiliximab was not administered and day +5 when two doses were administered. For patients receiving only one dose, in 2013 it was day +4.5 and in 2014 it was day +3.1. Creatinine on ICU discharge was significantly higher (1.11 vs 0.82, p < 0.05) in 2014, with no significant differences found for creatinine prior to transplantation, on hospital discharge or global or ICU stay. Vial consumption was 0.75/patient in 2013 and 1.5/patient in 2014, with a global cost difference of 31 301.37€.
Conclusion
In our population, the protocol change did not show any clinical benefits in the parameters assessed (creatinine and ICU/hospital stay). Preliminary estimation of 50% of patients not receiving the second dose after the protocol change was fulfilled.
References and/or Acknowledgements
Neuberger, et al. Delayed introduction of reduced-dose tacrolimus, and renal function in liver transplantation: the 'ReSpECT' study. Am J Transplant 2009. No conflict of interest.
There are various types of botulinum toxin type A. There is no defined relationship in the equivalent power between them.
Purpose
To analyse botulinum toxint type A (Dysport 500 U and Botox 50–100 U) usage for different indications, and to propose the one with the most favourable cost/efficiency ratio.
Material and methods
Different indications for which botulinum toxin type A was used were analysed from January to December 2013 in a third tier hospital.
Results
Distribution of Botox treated indications by service was as follows: neurology: migraines (38), spasmodic torticollis (9), blepharospasm (8) and spasticity (6); rehabilitation: spasmodic torticollis (28), hyperhidrosis (7), hemifacial spasm (28) and spasticity (75); dermatology: hyperhidrosis (26); urology: urinary incontinence due to neurogenic bladder (2). Dysport was used by the rehabilitation service to treat spasticity (132) and spasmodic torticollis (6). In spasmodic torticollis cases, the recommended Botox dose per patient and session is 240 U compared with 500 U for Dysport. Cost of Botox is 309.2€ versus 173.6€ for Dysport. Dysport implies theoretical savings of 43.85% per patient. During the studied period, of 43 patients suffering from spasmodic torticollis, 6 were treated with Dysport and 37 with Botox. In arm/leg spasticity cases, both were used. The recommended dosage of Botox per patient and session is 200–500 U compared with 750–1500 U for Dysport. Costs with Botox would be 309.2–618.5€ versus 347.2–520.8€ for Dysport. Hence Botox presents a theoretical saving of 10.9% per patient for low dosages, while with Dysport, savings are 15.8% in high dose cases. For other indications (75 patients) Botox was exclusively used because it was the only toxin with the approved indication or because it is the choice in these indications in our hospital.
Conclusion
Botox allows better economic dosage when few units are needed, as in cases of blepharospasm, hemifacial spasm or minor spasticity. For spasmodic torticollis and major spasticity, Dysport is the most cost effective option.
References and/or Acknowledgements
Botox and Dysport Summary of Product Characteristics. No conflict of interest.
Professional use of web 2.0 digital tools is increasing recently in the hospital pharmacy field. Symbaloo (www. symbaloo.com) is a free web-based tool that allows users to create a virtual desk to organise key information sources (links or documents) in a user-friendly and personalised page for free.
Purpose
The main objective of the study was to develop a Symbaloo digital desk for the pharmacy compounding area of a tertiary-level hospital.
Material and methods
A descriptive study was carried out in May 2018. A Symbaloo 'webmix' called 'Farmacotecnia' was created with a pharmacy department profile. The next step was to add links to the web, following the criteria shown below: Virtual documents, links and other web resources recommended by healthcare organisations, scientific associations or hospital pharmacy departments. Websites that comply with the basic recommendations of reliable health websites of the Health Quality Agency of Andalucia or have any web–quality seal such as 'Health on the Net Code' seal. Only Spanish– or English–speaking websites. Update up to 24 months before its inclusion on the webmix. Links of own documents were obtained to share from Google Drive web service. The webmix was published open access, after the pharmacy department checked the links and information.
Results
The Webmix 'Farmacotecnia' is available at https://www.symbaloo.com/mix/farmacotecnia. At 10 October 2018, the number of added links was 69, distributed in different categories: Official websites of scientific institutions related to compounding pharmacy (eight). Databases of compounding formulas and drugs (eight). Books, journals and other documents (18). Catalogues of paediatric formulae and other paediatric resources (10). News, bulletins, blogs, Twitter list and forum related to pharmacy compounding (four). Providers' websites (seven). Consultation documents, medical calculators and other web resources (14). The webmix is currently used by 95 Symbaloo users.
Conclusion
Symbaloo is a dynamic tool that supplies access and organisation of the most useful web resources for the pharmacy-compounding area team, and can also act as a 'filter' for the excessive health information available on the Internet. By this method, the search and information query becomes more simple, reliable and potentially efficient in terms of time and clicks saving.
Reference and/or acknowledgements
'Farmacotecnia'. Symbaloo.com. https://www.symbaloo.com/mix/farmacotecnia (accessed 15 October 2018). No conflict of interest.
The problem of severe asthma refractory to treatment has been addressed in clinical practice guidelines but there is still a notable percentage of patients poorly controlled, under treated and with inadequate follow-up. The pharmacy service (PS) of a third level hospital proposed a pharmaceutical care programme (PCP) to dispense omalizumab in prefilled syringes for self-administration in hospital and subsequently the patient would self-administer at home.
Aim and objectives
To evaluate the effectiveness and safety of treatment with omalizumab after implementation of a PCP for asthmatic patients treated with omalizumab in January 2019.
Material and methods
In this observational retrospective study, all patients treated with omalizumab in our hospital and who had started the PCP were included. The primary endpoint was the degree of effectiveness and safety of omalizumab in patients with the new protocol. The effectiveness indicators used to compare the study periods were: the number of exacerbations due to asthma, asthma control test for people over 12 years of age (ACT12 score) and clinical status assessment of asthma by a doctor (reduction in forced expiratory volume in 1 s (FEV1)). Exacerbation was defined as an increase in symptomatology that required systemic corticosteroid recovery treatment. Secondary endpoints included adherence to treatment and treatment modifications.
Results
A total of 28 patients were evaluated, 50% women, with a mean age of 24 years (8–56), and an average treatment duration with omalizumab of 29 months (1–66). Since the introduction of the PCP, 18% of patients suffered exacerbations (1–4) with an average ACT12 score of 11: 40% of patients showed an improvement in FEV1 and no patient reported a reaction at the injection site. Adherence to omalizumab was 96% but adherence to the basic treatment was only good in 45% of patients and was 0% in four patients.
Conclusion and relevance
Implementation of the PCP allowed follow-up of efficacy and safety of omalizumab treatment.
References and/or acknowledgements
1. European public assessment report of omalizumab (https://www.ema.europa.eu/en/documents/product-information/xolair-epar-product-information_en.pdf). I would like to express my great appreciation to the staff of the service. No conflict of interest.
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