Clinical Pharmacy Congress 2018

POSTER ABSTRACT BOOK

SESSION: FRIDAY PM

Contents

1. THE DEVELOPMENT AND IMPLEMENTATION OF A NEW CLINICAL PATHWAY TO SUPPORT THE

APPROPRIATE PRESCRIBING OF SPECIALIST INFANT FORMULA, ENSURING APPROPRIATE ONGOING CARE,

USING A MULTI-DISCIPLINARY TEAM APPROACH.............................................................................................. 3

PROJECT LEAD: ANGELA GILCHRIST, MEDICINES OPTIMISATION TEAM (MOT), NHS BURY CLINICAL COMMISSIONING GROUP

(CCG). ............................................................................................................................................................ 3 JANE WILSON NUTRITION AND DIETETIC SERVICE LEAD, COMMUNITY SERVICES BURY ........................................................ 3 JAYNE FIELDING PAEDIATRIC DIETITIAN, COMMUNITY SERVICES BURY. ............................................................................ 3

2. MPHARM STUDENT EXPERIENCES OF WORK BASED LEARNING AND PERCEPTIONS OF SUPPORT ................ 5

AMY VIGAR, BRADFORD TEACHING HOSPITALS FOUNDATION TRUST, BRADFORD .............................................................. 5 INTRODUCTION .................................................................................................................................................. 5

3. DRUG UTILISATION REVIEW OF RIVAROXABAN FOR TREATMENT OF VENOUS THROMBOEMBOLISM ......... 7

LAM KAR YI AUDREY, LEE ZHONG HUI KEITH, DEPARTMENT OF PHARMACY, CHANGI GENERAL HOSPITAL, SINGAPORE .............. 7

4. CLINICAL SIGNIFICANCE OF RISK FACTORS ASSOCIATED WITH HYPERTRIGLYCERIDEMIA IN PATIENTS ON

PARENTERAL NUTRITION ................................................................................................................................... 9

LEE ZHONG HUI, AUDREY LAM KAR YI, DEPARTMENT OF PHARMACY, CHANGI GENERAL HOSPITAL, SINGAPORE ...................... 9

5. ANTICOAGULANT THERAPY FOLLOWING MECHANICAL AORTIC AND MITRAL VALVE REPLACEMENT

SURGERY: ASSESSING ADHERENCE TO ROYAL BROMPTON & HAREFIELD TRUST’S AND INTERNATIONAL

GUIDELINES ...................................................................................................................................................... 10

GEORGINA FELL, ZAINAB KHANBHAI, AND SUKESHI MAKHECHA. ROYAL BROMPTON AND HAREFIELD NHS FOUNDATION TRUST

(RBHT), LONDON ............................................................................................................................................ 10

6. THE IMPACT OF SPECIALIST HIV PHARMACIST LED CONSULTATIONS IN A BUSY OUTPATIENT CLINIC ........ 12

HARDWEIR V, RICHARDSON C, SHAW M, SHIN LIM S, LEAKE DATE H ........................................................................... 12 BRIGHTON AND SUSSEX UNIVERSITY HOSPITALS NHS TRUST, PHARMACY, BRIGHTON ...................................................... 12

7. EVALUATING THE IMPACT OF AN ONCOLOGY PHARMACIST IN A NEW CANCER SERVICES UNIT ................ 13

BEENISH ALI, SPIRE WELLESLEY HOSPITAL, SOUTHEND-ON-SEA................................................................................... 13

8. RELATIVE COMPARISON OF LOADING DOSE CLOPIDOGREL (300 MG) VS. CONVENTIONAL DOSE (75MG) IN

DECREASING THE COMPLICATIONS OF ACUTE ISCHEMIC STROKE ................................................................... 15

SARA NIAFAR1, PHARMD, SAMANEH HAGHIGHI2, NEUROLOGIST, MOHAMMADREZA GHEINI2 , NEUROLOGIST ...................... 15 PHARMACEUTICAL SCIENCE BRANCH, ISLAMIC AZAD UNIVERSITY (IAUPS) .................................................................... 15 DEPARTMENT OF NEUROLOGY, TEHRAN UNIVERSITY OF MEDICAL SCIENCES (TUMS) ...................................................... 15

9. ASSESSING THE APPROPRIATENESS OF PRESCRIBING AND MONITORING ERYTHROPOIESIS STIMULATING

AGENT (ESAS) FOR THE TREATMENT OF ANAEMIA AMONG CKD PATIENTS IN SECONDARY HOSPITAL IN

QATAR, DOHA, QATAR ..................................................................................................................................... 17

AZZA H.B; KAWTHER M.A; MUTAZ I. ;ABDULALIM .S .............................................................................................. 17

10. AUDIT ON OMITTED DOSES ON ACUTE MEDICAL WARD (AMU). ............................................................... 19

KIRTI GODHANIYA, CROYDON UNIVERSITY HOSPITAL (CUH) & CROYDON ..................................................................... 19

11. COMPLIANCE TO FOUR MAIN COMPONENTS OF ANTIMICROBIAL SURGICAL PROPHYLAXIS IMPROVES IN

A LARGE PRIVATE HOSPITAL GROUP IN SOUTH AFRICA THROUGH PHARMACIST-DRIVEN QUARTERLY AUDITS

AND INTERVENTIONS ....................................................................................................................................... 21

MICHELLE GIJZELAAR, LIFE HEALTHCARE, SOUTH AFRICA ........................................................................................... 21

12. PHARMACY 2.0: EXPERIENCES OF USING WHATSAPP AS A REAL TIME COMMUNICATION TOOL TO

DELIVER OUT-OF-HOURS PHARMACY SERVICES .............................................................................................. 23

ANNA ROBINSON 1 DR ADAM RATHBONE 2 PAUL PARKER 2 RUTH NORRIS 1 DR WASIM BAQIR 1 PROFESSOR ANDREW HUSBAND 2

.................................................................................................................................................................... 23 NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST, NORTH TYNESIDE GENERAL HOSPITAL, RAKE LANE, NE29 8HN SCHOOL

OF PHARMACY, FACULTY OF MEDICAL SCIENCES, NEWCASTLE UNIVERSITY, NEWCASTLE UPON TYNE, NE2 7RU .................... 23

13. MEDICINES OPTIMISATION IN PATIENTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION OR

PATIENTS WITH MID-RANGE EJECTION FRACTION IN A COMMUNITY SETTING .............................................. 25

AL-ARKEE S1, FALADE J2, CAMPBELL G3, SAVAGE M3, THOMSON C3 ............................................................ 25 1 UCL SCHOOL OF PHARMACY ............................................................................................................................ 25 2 SCHOOL OF PHARMACY, UNIVERSITY COLLEGE LONDON .......................................................................................... 25 3 PHARMACY DEPARTMENT, GUY'S AND ST THOMAS' NHS FOUNDATION TRUST, LONDON............................................... 25

14. THE IMPACT OF A SENIOR CLINICAL PHARMACIST’S INTERVENTIONS ON PATIENT CARE–A SINGLE-

CENTRE PROSPECTIVE NATIONAL HEALTH SERVICE STUDY ACROSS NEUROLOGY AND NEPHROLOGY. .......... 27

CLARISSA CAPTUR, SENIOR CLINICAL PHARMACIST, DR GABRIELLA CAPTUR, DR NORBERT VELLA, PROF EMANUEL FARRUGIA,

MATER DEI HOSPITAL, MSIDA, MALTA, EUROPE. .................................................................................................... 27

15. THE BARNET ASTHMA STEP-DOWN GUIDELINE – SIMPLIFYING AND OPTIMISING ASTHMA TREATMENT

STEP-DOWN FOR PRESCRIBERS........................................................................................................................ 28

1. The development and implementation of a new clinical pathway to support the appropriate prescribing of specialist infant formula, ensuring appropriate ongoing care, using a multi-disciplinary team

approach. Project Lead: Angela Gilchrist, Medicines Optimisation Team (MOT), NHS Bury

Clinical Commissioning Group (CCG).

Jane Wilson Nutrition and Dietetic Service Lead, Community Services Bury

Jayne Fielding Paediatric Dietitian, Community Services Bury.

Introduction

In recent years the complexity and range of infant formulas available has resulted in

increasing costs, inappropriate prescribing and an increased burden on the

community paediatric dietetic service1.

The aims of the project were to:

Stop inappropriate prescribing of Over The Counter (OTC) formulas.

Reduce inappropriate prescribing of specialist formulas for Cow’s Milk Protein

Allergy (CMPA).

Support clinicians with diagnosis, initiation, management and discontinuation

of prescribed specialist formulas for children with CMPA.

Objectives

Develop a pathway to support clinicians with the correct diagnosis and

ongoing management of CMPA.

Review infants currently prescribed CMPA formula long-term, without

specialist input.

Implement national guidance regarding home re-challenge2, with the support

of health visitors.

Ensure future referrals to the dietetic service are appropriate and timely.

Promote the self-care agenda by ensuring OTC formulas are not prescribed.

Build a clinical guideline, based on the pathway, to embed within the GP

computer system to support decision making

Method

Development of new care pathway.

MOT technicians reviewed all prescribed formulas:

o OTC formulas stopped.

o Infants without specialist input referred to dietetic service.

Training sessions held for health visitors and clinicians.

Results

90 infants were referred to the dietetic service for review and support with the

milk ladder3.

33% reduction in the number of prescriptions for CMPA formula.

97% reduction in prescribing of OTC formulas.

Clinicians are using the guideline to support their decision making.

The health visitors are supporting the home re-challenge and onward referring

suitable infants to the dietetic service.

Conclusion

Joint working with MOT, clinicians, health visitors and dietitians has been

essential to the success of this project.

Clinicians now have a clear pathway for diagnosis and management of

CMPA.

Dietetic service now has the capacity to review infants in a timely manner.

The cost savings are exceeding expectations.

Ethics approval was not required for this project.

References

1. Greater Manchester guidance on prescribing infant formula for cow’s milk

protein allergy in primary care May 2016. Available from

http://gmmmg.nhs.uk/html/guidance.html

2. The MAP Guideline (Milk Allergy in Primary Care) home re-challenge 2014.

Available from

http://cowsmilkallergyguidelines.co.uk/downloads-and-

resources/downloadable-map-home-challenge/

3. The MAP Guideline (Milk Allergy in Primary Care) milk ladder February 2014.

Available from http://cowsmilkallergyguidelines.co.uk/downloads-and-

resources/downloadable-map-milk-ladder/

Acknowledgement

Health visiting team, Community Services Bury

2. MPharm Student Experiences of Work Based Learning and Perceptions of Support

Amy Vigar, Bradford Teaching Hospitals Foundation Trust, Bradford

Introduction

Work based learning (WBL) is a principle pedagogy to ensure pharmacy graduates

are fit for purpose, as outlined by the GPhC1 and Modernising Pharmacy Careers2.

Knowledge recontextualisation3 (a WBL concept) aims to optimise student learning

by supporting movement of learning between the workplace and academic institute.

Students’ require support in both environments to facilitate KR4, however, there is no

research on KR in undergraduate MPharm training.

Objectives

1. Investigate undergraduate UoB MPharm students experiences of WBL

2. Identify student perceptions of current support of KR

3. Identify pedagogical changes to improve KR

Method

Design: A mixed methods approach combining surveys of stakeholders and semi-

structured student interviews with thematic data analysis.

Ethics: Ethics approval was sought and received by University of Leeds and

University of Bradford.

Data Source: 4th year undergraduate University of Bradford (UoB) MPharm students,

UoB Pharmacy Department Teaching Staff & WBL workplace tutors.

Results

Students identified 84 examples of KR (see table 1). Tutors and students agreed KR

occurred in both environments. Perceptions of the supportive measures were

divided. Thematic analysis identified all groups felt integration between environments

was lacking and hindered KR.

Table 1. Examples of KR and Supportive Measures

Knowledge Recontextualisation

Total number of examples cited by students

Number of KR examples using

clinical knowledge

Number of KR examples using

professional knowledge

Other

University to Workplace

51 37 (72.5%) 7 (13.8%) 7

(13.8%)

Workplace to University

33 13 (39.4%) 20 (60.6%) 0 (0%)

Total 84

Number of examples where support for KR identifiable

14 (12 attributed to workplace staff, 2 attributed to debrief seminar) “Staff ask questions and prompt you to think on the spot and recollect

what you have learnt. This is engaging.” (Student Interview)

Discussion

KR was evident in the workplace and university, reasserting KR theory of knowledge

transfers between both environments. Generally, professional knowledge and

theoretical knowledge were transferred to the university and workplace, respectively.

Tutors and students perceived a loss of continuity, particularly the absence of

teacher practitioners (TPs), between the workplace and university as having various

adverse effects on optimising KR. Increasing TP provision is an unlikely resolution

due to financial constraints on the NHS and academic institutes. The findings

suggest skill sharing between university and workplace tutors and greater active

integrated support is required to optimise KR and mitigate the lack of TPs.

References

1. General Pharmaceutical Council. Future Pharmacists: Standards for the initial

education and training of pharmacists. London: General Pharmaceutical Council:

2010.

2. Guile D, Ahamed F. Modernising the Pharmacy Curriculum: A report for the

Modernising Pharmacy Careers Pharmacist Undergraduate education and Pre-

registration training review team. London: Institute of Education, Faculty of Policy

& Society, University of London: 2009.

3. Evans K, Guile D, Harris J. Putting Knowledge to Work. London: Institute of

Education, University of London: 2009.

4. Eraut, M. How Researching Learning at Work can Lead to Tools for Enhancing

Learning. The Sage Handbook of Workplace Learning. London: Sage

Publications Ltd: 2011.

3. DRUG UTILISATION REVIEW OF RIVAROXABAN FOR TREATMENT OF VENOUS THROMBOEMBOLISM

Lam Kar Yi Audrey, Lee Zhong Hui Keith, Department of Pharmacy, Changi General

Hospital, Singapore

Introduction

Rivaroxaban is a selective factor Xa inhibitor indicated for the treatment of venous

thromboembolism (VTE). In view of their relatively recent introduction into the

market, the risks and higher costs compared to warfarin, we aim to highlight the

usage pattern of rivaroxaban in the hospital, incidence of adverse drug reactions,

and associated clinical outcomes in patients with venous thromboembolism.

Objective(s)

To determine (1) prescribing patterns, (2) clinical outcomes and (3) investigate the

incidence of rivaroxaban-associated adverse drug events.

Method

A retrospective cohort study (ethics approval not required) was performed in all adult

patients receiving rivaroxaban for the treatment of VTE between 1st June 2014 to

30th June 2015. Data collected included patient demographics, dosing regimens,

adverse drug events, and associated clinical outcomes.

Results

Eighty-three patients (mean age = 62.2) were included in the study. Dosing

regimens were appropriate for 91.6% of patients. A total of 54 patients (65.0%) were

treated for the appropriate duration of 6 months with total resolution of VTE. Eleven

patients were treated for a shorter than recommended duration of 6 months due to

cost issues, deterioration of renal function and/or adverse drug events. Apart from 3

patients who passed away, 9 patients (10.8%) developed an adverse clinical

outcome (three PE cases, four recurrent DVT cases, and one case each of

ischaemic stroke and myocardial infarction). Eight patients (9.6%) developed non-

major bleed (viz., hematuria, mild mucosa bleeding), while one (1.2%) experienced

dyspepsia. There was also one documented case of intracranial haemorrhage which

resulted in discontinuation of rivaroxaban therapy.

Conclusion

Dosing regimens used for the treatment of VTE were generally appropriate.

Mortality rate amongst patients was low although it was not possible to establish a

causal link to the use of rivaroxaban. Rivaroxaban was generally well tolerated, and

adverse drug events affected approximately one-tenth of all patients, which was

similar to that of previous literature reports.

References

1. Oral Rivaroxaban for the Treatment of Symptomatic Pulmonary Embolism. New

England Journal of Medicine. 2012;366(14):1287-1297.

2. Prins M, Lensing A, Bauersachs R, van Bellen B, Bounameaux H, Brighton T et

al. Oral rivaroxaban versus standard therapy for the treatment of symptomatic

venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE

randomized studies. Thrombosis Journal. 2013;11(1):21.

3. Rivaroxaban: drug Information. Lexi-Comp OnlineTM, Hudson, OHIO:Lexi-Comp,

Inc.: Last accessed on 15 September 2016

4. Oral Rivaroxaban for Symptomatic Venous Thromboembolism. New England

Journal of Medicine. 2010;363(26):2499-2510.

5. Kearon C. Antithrombotic Therapy for Venous Thromboembolic Disease *. Chest.

2008;133(6_suppl):454S.

4. Clinical significance of risk factors associated with hypertriglyceridemia in patients on parenteral nutrition

Lee Zhong Hui, Audrey Lam Kar Yi, Department of Pharmacy, Changi General

Hospital, Singapore

Parenteral Nutrition (PN) is indicated for patients who are unable to take in feeding

enterally or orally. Several factors have been postulated to be the cause of

hypertriglyceridemia, such as the presence of infections, the use of various drugs, as

well as the patients' pre-existing comorbidities such as diabetes, obesity or hepatic

and renal impairment.

This study aims to determine the patient profile and usage pattern of PN in hospital,

as well as to investigate the risk factors that may predispose a patient on PN to

hypertriglyceridemia.

A retrospective cohort study was conducted on adult patients in whom PN was

administered between the dates 1 January 2016 to 31 December 2016. Data

collected include patient demographics and pre-existing comorbidities, indication for

use of PNs as well as the duration of the PN and the lipid infusion used. Relevant

laboratory parameters will be obtained prior to, one week after initiaiton, and

discontinuation of PN. Data on PN use to be collected include liver function tests,

creatinine clearance, renal panel and lipid profile. The outcome measures include

the incidence of hypertriglyceride levels in patients (TG > 0.56mmol/L). Ethics

approval was not required for this retrospective study.

Table 1. Indication of Parenteral Nutrition

Intestinal Obstruction 16

Anticipated Prolonged NBM 30

Post-operative ileus 18

Fistula 3

Pancreatitis 1

Others 7

A total of 74 patients were analyzed, out of which 27 patients (36%) were deemed to

have developed hypertriglyceridemia. A scoring system was used as an indication of

the risk factors that patient had (1-6). Patients typically had an average of 2.56 score

of risk factors. The use of propofols and the presence of liver failure seemed to be

leading causes of developing hypertriglyceridemia, however, due to the small sample

size; the results is not statistically significant. Nevertheless, this study serves as a

starting point for future and more extensive investigations into a wider scope of

patients.

References:

1. Llop, J., Sabin, P., Garau, M., Burgos, R., Pérez, M., & Massó, J. e. ). The importance of clinical factors in parenteral nutrition-associated hypertriglyceridemia. Clinical Nutrition. Clinical Nutrition 2003; 22(6): 577-583.

2. Mirtallo, J., Dasta, J., Kleinschmidt, K., & Varon, J. State of the Art Review: Intravenous Fat Emulsions: Current Applications, Safety Profile, and Clinical Implications. Annals of Pharmacotherapy 2010; 44: 688-700.

3. Geert J.A. Wanten. Parenteral lipid tolerance and adverse effects: Fat Change for Trouble. Journal of Parernteral and Enteral Nutirtion 2015; 39: 33-38.

4. Martin A. Crook. Lipid Clearance and Total Parenteral Nutrition: The importance of Monitoring Plasma Lipids. Clinical Nutiriton 2000; 16: 774-775

5. Anticoagulant therapy following mechanical aortic and mitral valve replacement surgery: assessing adherence to Royal Brompton & Harefield Trust’s and international guidelines

Georgina Fell, Zainab Khanbhai, and Sukeshi Makhecha. Royal Brompton and

Harefield NHS Foundation Trust (RBHT), London

Introduction:

Following implantation of a mechanical heart valve prosthesis, anticoagulation with warfarin is a life-long requirement. Target international normalised ratios (INRs) vary, depending on the thrombogenicity of a prosthesis and patient-related factors such as atrial fibrillation (AF). [1] The RBHT Oral Anticoagulant Therapy guideline recommends INR target ranges for warfarin and is largely based on the 2011 national guideline published by the British Committee for Standards in Haematology. [2] Since 2011, there have been several new and improved valves that have been introduced. In 2017 the American Heart Association (AHA) and the European Society of Cardiology (ESC) published updated guidelines for the management of valvular heart disease. [3-4]

Objectives:

1. To establish whether patients are being appropriately anticoagulated following mechanical aortic valve replacement (AVR) and mitral valve replacement (MVR) surgery

2. To assess whether clinical practice complies with the trust’s standards for target INR ranges following mechanical AVR and MVR surgery

3. To compare current guidance against international standards

Methodology:

Ethics approval was not required for this study. Patients who underwent AVR and MVR surgery at Harefield Hospital from January to December 2017 were retrospectively identified and included. Patients who died peri-operatively were excluded. Data was collected on the type of surgery, mechanical model fitted, anticoagulation, and INR target ranges. In total, 48 patients were reviewed.

Results:

Table 1: Adherence of clinical practice to trust and international guidelines for different target INR indications post-mechanical AVR and MVR surgery Target INR indications (n=48)

RBHT target INR ranges

RBHT (n, %) [2]

AHA and ESC target INR ranges

AHA and ESC

(n, %) [3-4]

AVR St Jude model (n=25)

2.5-3.5 12 (48) 2.0-3.0 9 (36)

AVR St Jude model w/ AF (n=2)

a a 2.5-3.5 2 (100)

AVR with prosthesis other than St Jude modelb (n=5)

3.0-4.0 1 (20) 2.0-3.0 2 (40)

AVR with prosthesis other than St Jude modelb and AF (n=1)

a a 2.5-3.5 0 (0)

MVR with St Jude model (n=15)

3.0-4.0 9 (60) 2.5-3.5 5 (33)

aAs per consultant’s individual patient risk assessment bCarbomedics was the only other mechanical model used, and was regarded as having a low thrombogenecity according to ECS classification [4] Of the 48 patients assessed, 100% were anticoagulated with warfarin. 22 patients (46%) had target INR ranges that complied with trust guidelines and 18 (38%) were in accordance to international standards. It was not possible to ascertain adherence to trust guidelines for patients with AF as this was not stated in the guideline.

Conclusion:

This study demonstrates that there is varying practice with regards to target INR ranges post-mechanical AVR and MVR surgery at Harefield Hospital. RBHT Oral Anticoagulant Guidelines require updating to provide more detailed, consistent recommendations in line with international guidance.

References:

1. David Keeling, Trevor Baglin, Campbell Tait et al; Guidelines on oral anticoagulation with warfarin – fourth edition; British Journal of Haematology; 2011; 154; 311-324.

2. Natalie Turner, Louise Tillyer, Beejal Shah. Guidelines for the use of oral anticoagulant therapy with warfarin; Version 4; Royal Brompton and Harefield NHS Foundation Trust; 2016; 1-22.

3. Rick Nishimura, Catherine Otto, Robert Bonow et al; 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease; AHA/ACC guideline; 2017; 135; e1159-e1195.

4. Helmut Baumgartner, Volkmar Falk, Jeroen Bax et al. 2017 ECS/EACTS guidelines for the management of vascular heart disease; European Heart Journal; 2017; 38; 2739-3786.

6. The Impact of Specialist HIV Pharmacist Led Consultations in a busy Outpatient Clinic

Hardweir V, Richardson C, Shaw M, Shin Lim S, Leake Date H

Brighton and Sussex University Hospitals NHS Trust, Pharmacy, Brighton

Background

Antiretroviral therapy (ART) is life-long and often complex with a high propensity for

drug-drug interactions. Specialist HIV Pharmacists are best placed to advise on the

choice of therapy to monitoring adherence, drug-drug interactions, and adverse

events.

Objectives

To identify the interventions made by the Specialist HIV Pharmacists during their

face to face consultations with patients in a busy outpatient HIV clinic.

To assess the reasons for ART switches.

Method

A retrospective review of case notes for the period January 3rd until December 29th

2017 was conducted. The clinic database was accessed to identify the patients who

were seen in a Pharmacist ART clinic within that period. Ethics approval was not

required as this was a service evaluation and all data was anonymised.

Results

There were 573 Specialist HIV Pharmacist led consultations. Information was

available for 512 (89%). On average patients had 1 consultation (range 1-4). 82% of

the consultations, involved a treatment modification to the patients’ regimen. The

main reason for treatment changes was adverse events & toxicity (69%). Adverse

events reported included central nervous system and gastrointestinal side-effects.

ART was also reviewed in patients who had bone abnormalities such as osteopenia

& osteoporosis, patients who had an increased risk of developing cardiovascular

events and patients who had renal impairment.153 interventions were recorded and

75% of those recorded was for advice relating to drug-drug interactions.

Discussion

Specialist HIV Pharmacists have an essential role in supporting patients with lifelong

adherence to ART. Despite the advances made in ART, patients are more likely to

switch regimens due to adverse events & toxicity. The propensity for drug-drug

interactions is high with ART and with expanded coverage in addition to an ageing

cohort, it is essential that clinics have access to a Specialist HIV Pharmacist.

7. Evaluating the impact of an oncology pharmacist in a new cancer services unit

Beenish Ali, Spire Wellesley Hospital, Southend-on-Sea

Background

There are approximately 360,000 new cancer cases in the UK each year1 and 28%

of patients diagnosed with cancer, received chemotherapy in England between 2013

and 20142. To meet this ever increasing demand of chemotherapy treatments, a

new role of an oncology pharmacist was created in a private hospital. This was to

ensure a robust process management of chemotherapy within the hospital and to

address the pharmaceutical care needs of the oncology patients.

Objectives

To evaluate the impact of a pharmacist within the oncology multi-disciplinary team

(MDT). The primary objectives were to establish the number and types of

pharmaceutical care interventions and assess the impact on patient care and the

wider MDT.

Method

Between November 2017 and January 2018, the oncology pharmacist worked as

part of the MDT, attended pre-assessment clinics and consulted patients at each

cycle of chemotherapy- a maximum of 15 patients were seen each week. The clinical

interventions were recorded daily on a database and divided into patient facing and

non-patient facing interventions.

Ethics approval was not required for data collection in this audit as patient specific

data was not collected.

Results

Table 1: An overview of the pharmacist interventions over the three month period.

Basis of patient facing interventions Frequency

Nausea and vomiting 2

Neuropathy 3

Hypersensitivity reactions 2

Patient unwell to receive treatment 3

Pain management 3

Constipation 2

Skin reactions 2

Advice on oral hygiene 15

Diarrhoea 10

General advice/reassurance 25

Hypomagnesaemia 2

Reflux symptoms 3

Other 7

Basis of non- patient facing interventions Frequency

Neutropenia 6

Blood results requiring consultant attention 4

Dose queries 6

Managing pre-medication/discharge medication 3

Other prescribing queries 20

Discussion

A total of 118 interventions were made by the oncology pharmacist, out of which 79

were patient facing interventions. The interventions were varied at each

chemotherapy cycle, where the patients discussed their side effects and general

concerns around longevity of treatment cycles, required encouragement, as well as

advice on managing their lifestyle with the disease. The pharmaceutical issues were

identified and addressed in a timely manner and on three occasions, the patients

were urgently referred to A&E as they were rendered too unwell to receive treatment.

The feedback from the wider MDT highlighted a positive impact of pharmacy

presence towards the patients and an integral supportive role of the pharmacist was

recognised within the team as a whole.

References

1. Cancer Research UK. Cancer diagnosis and treatment statistics. (2015). Accessed Feb 2017 from http://www.cancerresearchuk.org/health-professional/cancer-statistics/diagnosis-and-treatment#heading-Two

2. Cancer Research UK. Cancer diagnosis and treatment statistics. (2015).

Accessed Feb 2017 from http://www.cancerresearchuk.org/health-

professional/cancer-statistics/diagnosis-and-treatment#heading-Five

8. Relative Comparison of Loading dose Clopidogrel (300 mg) vs. Conventional Dose (75mg) in Decreasing the Complications of

Acute Ischemic Stroke Sara Niafar1, PharmD, Samaneh Haghighi2, Neurologist, Mohammadreza Gheini2 ,

Neurologist

Pharmaceutical Science Branch, Islamic Azad University (IAUPS)

Department of Neurology, Tehran University of Medical Sciences (TUMS)

Background and Objective: Stroke is one of the leading causes of morbidity and

mortality in the world. Patients surviving acute ischemic stroke or transient ischemic

attack (TIA) are at an increased risk for subsequent stroke1. Consistent with this

notion, Antiplatelet agents are the mainstay for secondary prevention of non-

cardioembolic stroke. A number of studies have indicated that Clopidogrel inhibits

platelet aggregation in these patients, so that Clopidogrel loading dose has been

more effective than maintenance dose in reducing the risk of subsequent stroke and

vascular events without increasing the risk of bleeding events in patients which have

already had an episode of stroke or TIA2. In this study, we aimed to evaluate the

comparative efficacy of Clopidogrel loading dose vs. standard dose in decreasing the

complications of acute ischemic stroke in patients admitted to Sina Hospital.

Methods and Materials: In this double-blinded clinical trial, 76 patients with

ischemic stroke referring to Sina hospital were assigned in two groups: The first

group received Aspirin 80mg and Clopidogrel 75mg plus 225mg placebo at baseline,

followed by Clopidogrel 75mg and Asprin80 mg daily for 30 days, whereas the

second group received Asprin 80mg and Pidogrel 300mg in the first day, followed by

Clopidogrel 75mg and Asprin 80mg daily for 30 days. Two weeks later, improvement

of the patients was compared. All patients were monitored for neurologic

deterioration to detect symptomatic ICH within 7 days after stroke. Also, they were

followed for any new bleeding event and recurrent stroke within 1 month.

Results: In this study, 76 patients, including comprising 41 male (53.9%) and 35

women (46.05%), mean age 67.45±6.85 years were evaluated. The difference

between the two groups in terms of age, sex, and risk factor of stroke was not

statistically significant. Based on MRS and Barthel scores, the level of improvement

after 2 weeks was remarkably higher than the group received loading dose

Clopidogrel compared to that of standard dose (P<0.05). The correlation between

NIHSS, MRS, and Barthel scores with age, sex, and the risk factor of ischemia were

not statistically significant (P>0.05). Besides, the frequency of symptomatic ICH or

any bleeding event in the group taken the loading dose Clopidogrel was not

significantly higher than those received standard dose (P=0.43)

Conclusion: Our data have shown that administration of loading dose Clopidogrel

after ischemic stroke (within 24 hours), not only augmented neurologic improvement

as well as daily activities in patients with acute ischemic stroke, but also did not

increase the risk of hemorrhagic complications.

Key words: Clopidogrel, Loading Dose, Acute Ischemic Stroke

1. Sofi F, Marcucci R, Gori AM, Giusti B, Abbate R, Gensini GF. Clopidogrel

nonresponsiveness and risk of cardiovascular morbidity. An updated meta-analysis.

Thromb Haemost 2010;103:841–8.

2. Maree AO, Fitzgerald DJ. Variable platelet response to aspirin and clopidogrel in

atherothrombotic disease. Circulation 2007;115:2196–207.

9. Assessing the Appropriateness of Prescribing and Monitoring Erythropoiesis Stimulating Agent (ESAs) for the Treatment of Anaemia among CKD patients in Secondary hospital in Qatar,

Doha, Qatar Azza H.B; Kawther M.A; Mutaz I. ;Abdulalim .S

Background

In 2011, U.S. Food and Drug Administration send safety announcement of modified

recommendation for conservative dosing of ESAs in patients with CKD to improve

the safe use of these drugs. Many reports linked the inappropriateness using of this

drug with high cardiovascular events.

Aim& Objectives--- to investigate if prescribing and monitoring ESAs among CKD

patients in the hospital is appropriate according to KDOQI clinical recommendation

Guidelines 2006 along with FDA safety announcement 2011.

Method--- cross-sectional study using data of 90 patients who attend the dialysis

and nephrology outpatients in alkhor hospital (North Qatar) and using several doses

of ESAs between November 2014 and April 2015 .Data collected through check list

include also basic demographic information, disease stage, type of ESAs,

appropriate initiation of ESAs, appropriate monitoring of Hgb, appropriate rout of

administration and concurrent administration of iron supplement.

Key findings--- of 94 patients who received several doses of ESAs and met the

inclusion criteria, 90 (95.7%) were recruited in this study.

The prescribing preference between Erythropoietin and Darbepoietin is almost equal

57.1% and 42.9 % respectively. Most of the patients initiated ESAs treatment when

their Hgb level greater than 10 mg/dl (65.6%) which is not recommended by

guidelines. Weight based dosing was applied for 33 patients only (36.7%).Most of

the patients (84.4 %) have checked for Hgb level at weekly basis, This explained

why more than half of the patients (57.8%) have Hgb level at the end greater than

11.5 gm/dl. Addition of Iron supplement and using correct route of administration

were according to guidelines in 73 patients (81.1%) and 71 (78.9%) respectively. All

the patients were not provided with Medication Guide.

Conclusion

The findings showed suboptimal prescribing of ESAs for CKD patients in Al Khor

Hospital .Overcorrection of anemia is common and no education is provided to the

patients

Abbreviations

CKD…………………………………………………………Chronic Kidney Disease

KDOQI………………………………Kidney Disease Outcomes Quality Initiativ

References

Abdul Kareem, A., Ali A, Jamal A. (2007) .The Gulf Survey of Anaemia Management

, Saudi Journal of Kidney Diseases and Transplantation, vol 18 issue 2, pp 206-214

[Online] available from

http://faculty.ksu.edu.sa/12977/Document

American Society of Health System Pharmacists (ASHP) (2008). Formulary

Management Guideline ASHP Guidelines on Medication Use Evaluation. Am J Hosp

Pharm pp: 169-171, online available from

www.ashp.org

Brenner, RM., et al. (2005). Rational –Trial to Reduce Cardiovascular Events with

Aranecept Therapy (TREAT): evolving the management of cardiovascular

10. Audit on omitted doses on Acute Medical Ward (AMU). Kirti Godhaniya, Croydon University Hospital (CUH) & Croydon

Introduction

Omitted or delayed doses of prescribed drugs can jeopardise patient care, safety and potentially cause deterioration of condition or treatment failure. A review of medication incidents by the NPSA in 2007 revealed that omitted and delayed medicines was the second largest cause of medication incidents reported [1]. The data highlighted that for some kinds of medicines, such as antibiotics, anticoagulants and insulin, an omitted or delayed dose can have serious and even fatal consequences.

Objectives

Aim is to understand and examine the common types of reasons provided for critical inappropriate omissions (IO) on Acute medical unit. Objectives: a) Inappropriately omitted doses for all 8am doses b) Where the nurses are looking for ‘medications unavailable’ c) Whom the nurses are informing if ‘medications unavailable’ d) Whether the omitted medicine was a stock medication e) Whether nurses are raising an order for non-stock items f) Whether nurses know which medicines are critical g) Whether overdue medications (doses not signed for) were truly not given and why they were not signed.

Method

Reports were generated using CRS-millennium for critical 8am scheduled doses over a one-week period. The raw data was then fed through a validated database. This generated a report and based on this a data collection tool was created, nurses were interviewed and the information gathered was analysed. No ethical approval was required.

Results

Table 1 - Results

Objective a 44 critical IO doses were identified:

79.5% (35) doses were recorded as not signed for

11.4% (5) doses were reordered as nil by mouth

9.1% (4) doses were recorded as medication unavailable Results for medication unavailable (n=4)

Objective b

60% asked patient if they had it with them/ bring from home

100% looked in the drug trolley

90% looked in the patient locker

25% looked in the fridge

4% looked in the treatment room

Objective c

80% informed nobody

20% informed the pharmacist Objective d 100% items were stock items

Objective e 100% of nurses raised an order for non-stock items

Objective f (n=44) 71% were aware it was critical, 27% were not aware and 2% were unsure Results for ‘not signed for’ (n=35)

Objective g 54% (19) were actually administered and 46% (16) were not. Reasons for not signing include:

Interruption during medication round

forgetting due to high workload/pressure

went to the treatment room and forgot to sign

left it unsigned to prompt them to administer dose later in the day

Discussion

On the whole this audit uncovered a high rate of inadequate record keeping as majority of critical IO doses were ‘not signed for’. This is considered unacceptable practice that could leave both patients and nurses vulnerable. Recommendations include to consider a ‘zero tolerance to blank boxes’ policy as a safety initiative, implement action cards on the ward which outline the appropriate steps to follow If medication is unavailable, and to Identify a list of critical medicines where timeliness of administration is crucial.

References

1. National Patient Safety Agency Rapid Response Report. Reducing Harm from Omitted and Delayed Medicines in Hospitals. (2010) NPSA/2010/RRR009. tinyurl.com/NPSA-Meds

11. Compliance to four main components of antimicrobial surgical prophylaxis improves in a large private hospital group in South

Africa through pharmacist-driven quarterly audits and interventions

Michelle Gijzelaar, Life Healthcare, South Africa

Introduction

Antimicrobials used for surgical prophylaxis is an area of high utilisation.

Inappropriate use of antimicrobials for surgical prophylaxis can contribute to an

increase in surgical site infections (SSI’s), adverse events and widespread

antimicrobial resistance.1 A need was identified for a structured quarterly audit

process to be implemented to measure compliance to evidence-based guideline

recommendations and drive improvement.

Objectives

The objectives for this project were to develop a consolidated surgical prophylaxis

guideline appropriate in the South African context based on local and international

evidence-based recommendations, determine baseline compliance and drive

improvement.

Method

A surgical prophylaxis guideline was developed through consolidating local and

international guideline recommendations.1,2,3,4,5 Microbiologist input was obtained to

ensure the appropriateness of the recommendations according to local SSI statistics.

Quarterly audits by pharmacists commenced in April 2017 across 41 hospitals.

Pharmacists were tasked to evaluate all surgical patients, particularly in (but not

limited to) intensive care-, high care-, maternity-, orthopaedic and general surgical-

wards on a self-determined date during the audit month. Ethics approval was not

required due to the project being an audit-based process.

Results

Over a one year period, four audits were conducted. Compared to the baseline audit,

overall compliance according to January 2018 results improved from 65.5% (n=927)

to 73.1% (n=1638). Improvement was seen in all four categories measured namely

correct drug, dose, timing of administration and duration as per Table 1 below.

Table 1: Average compliance to surgical prophylaxis guidelines per audit element Apr-17 Jul-17 Oct-17 Jan-18

Drug used 70% 68% 71.54% 73.49%

Dose prescribed 66% 64% 73.87% 75.32%

Timing of administration 71% 66% 75.50% 78.28%

Duration of antimicrobial surgical prophylaxis 55% 51% 59.01% 73.12%

Conclusion

Through focussed interventions such as quarterly surgical prophylaxis audits,

stewardship can improve. Audits enable pharmacists to identify areas of

inappropriate utilisation, and drive compliance through a structured process.

References

Allegranzi, B., Bischoff, P., Kubilay, Z. et al; Global guidelines for the prevention of

surgical site infection; World Health Organization (WHO) guidelines; 2016; Available

from: http://www.who.int/gpsc/ssi-guidelines/en/

Ah-See, K., Ballantyne, E., Begg, A. et al; Antibiotic prophylaxis in surgery; Scottish

Intercollegiate Guidelines Network (SIGN) guidelines; 2014; Available from:

http://www.sign.ac.uk

Wasserman, S., Boyles, T. & Mendelson, M.; A pocket guide to antibiotic prescribing

for adults in South Africa; South African Antibiotic stewardship Programme (SAASP)

guidelines; 2015; Available from:

www.fidssa.co.za/.../Documents/SAASP_Antibiotic_Guidelines

Samuel, R., Nel, D., Joubert, I. et al; Guidelines for infection control in anesthesia in

South Africa; South African Society of Anesthesiologists (SASA) guidelines; 2014;

Available from:

anaesthetics.ukzn.ac.za/Libraries/...Control_Guidelines_SASA.sflb.ashx

Bratzler, D.W., Patchen, E., Olsen, K.M. et al; Clinical practice guidelines for

antimicrobial prophylaxis in surgery; American Journal of Health-System Pharmacy;

2013; Volume 70; p.195 – 283

12. Pharmacy 2.0: Experiences of using WhatsApp as a real time communication tool to deliver out-of-hours pharmacy services

Anna Robinson 1 Dr Adam Rathbone 2 Paul Parker 2 Ruth Norris 1 Dr Wasim Baqir 1

Professor Andrew Husband 2

Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital,

Rake Lane, NE29 8HN School of Pharmacy, Faculty of Medical Sciences, Newcastle

University, Newcastle upon Tyne, NE2 7RU

Introduction/Background/Context

In an era of rapid technological advances, healthcare professionals are embracing

modern methods of communication to support their work. Research in this area

shows there are multiple factors influencing how technologies are used, and the

impact that they have on practice.1 WhatsApp has received attention due to its ability

to integrate whole team communications, via group discussions, into everyday

working practices.2 Literature has evaluated its use in nursing and surgical teams.

However, there is currently no evaluation within pharmacy teams.

Objectives

The purpose of this study was to explore the experiences of a pharmacy team using

WhatsApp to support out-of-hours service delivery.

Method

A qualitative phenomenological study was designed using interview and focus group

methods. Twenty-seven participants were recruited via email. Data collection was

conducted on-site at a secondary care organisation in North East England.

Participants included junior, middle, and senior grades of pharmacy professionals

(25 pharmacists and 2 pharmacy technicians). This project received ethical approval

from Newcastle University, School of Pharmacy Ethics sub-committee.

Results

The study identified five main themes describing participants' experiences of using

WhatsApp. These were: (1) professional development, (2) legal responsibility, (3)

professional relationships (4) work-life balance and (5) efficiency of communication.

Overall, participants had positive experiences using WhatsApp; improving their

ability to deliver accurate and safe out-of-hours pharmacy services, ensuring high-

quality patient care. Some participants expressed concern regarding training when

using WhatsApp, and the legal implications this may have if practices were deemed

inappropriate. Additionally, results captured anxiety about how personal practices

may be compared to the practice of others, if shared on the group.

Discussion/Conclusion

This research highlights the innovation of WhatsApp as a communication tool,

promoting collaborative working amongst clinical sectors to support patient care.

Given social media’s infiltration into work systems, further reproducible studies of this

nature would prove useful for investigating WhatsApp’s enhanced pharmacy service

provision.

References

1. Mars M, Scott RE. WhatsApp in Clinical Practice: A Literature Review. Studies in

health technology and informatics 2016;231:82-90.

2. Ganasegeran K, Renganathan P, Rashid A, et al. The m-Health revolution:

Exploring perceived benefits of WhatsApp use in clinical practice. International

journal of medical informatics 2017;97:145-51.

13. Medicines Optimisation in Patients with Heart Failure with Reduced Ejection Fraction or Patients with mid-range Ejection

Fraction in a Community Setting AL-ARKEE S1, FALADE J2, CAMPBELL G3, SAVAGE M3, THOMSON C3

1 UCL School of Pharmacy

2 School of Pharmacy, University College London

3 Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London

Background:

Heart Failure (HF) is defined as a complex clinical syndrome. [1] HF can be divided

into three categories: those with reduced ejection fraction (HFrEF), those with Mid-

Range Ejection Fraction (HFmrEF), or those with Preserved Ejection Fraction

(HFpEF). [2]

The clinical guidelines present the three key therapeutic agents: Angiotensin-

converting enzyme inhibitors (ACEIs) or Angiotensin receptor blockers (ARB),

Mineralocorticoid/ Aldosterone receptor antagonists (MRA) and Beta blockers (BB)

that have shown to improve survival and reduce hospitalistion. However, there are

several cases where suboptimal doses of heart failure medications are used in

clinical practice. [3][4]

Aim:

To evaluate whether medicines optimisation appropriately occurred in patients with

HFrEF or patients with HFmrEF prior to discharge from a community setting.

Objectives:

• To determine if optimal titration of heart failure medicines was achieved prior to

discharge from the community heart failure team.

• To describe the reasons why patients were not on maximum licensed dose at the

point of discharge.

Method:

Study site: Guy's and St Thomas' NHS Foundation Trust.

Study design: A retrospective service evaluation study.

Study population: all adults (aged ≥ 18) patients with (HFpEF) (EF<40%) or

(HFmrEF) (EF40-49%) who were discharged from the community HF team between

July 2016-March 2017.

Data collection: From Carenotes electronic record and subsequent analysis with the

software SPSS version 24.

Ethics approval was not required as this was a service evaluation.

Optimal dose is defined as maximum licensed dose (MLD) or maximum

tolerated dose (MTD).

Suboptimal dose is below MLD or below MTD.

Results:

198 patients with heart failure were analysed. The % of patients on optimal dose at

discharge: 75.2% on ACEI/ARB, 82.3% on BB and 39% on MRA. The most common

limitation to reach MLD was Hypotension (28.3%). This study also reported the

proportion of the patients who underwent an adherence assessment when they were

referred to heart failure team using the Moriskey adherence questionnaire. Of 62.6%

that completed the assessment, 90% reported adherence.

Discussion/Conclusion:

This study indicates that a high proportion of patients received key evidence-based

medicines on discharge from a community heart failure service. The major factor

limiting heart failure medicines optimisation included patients' clinical status and non-

clinical factors. Plans, there is more scope for improvement in the community

service, specifically in context to documentation of several data processes and

adherence assessments.

References:

1. National Institute of Health and Clinical Excellence (NICE), Chronic heart

failure in adults: management, August 2010; CG108 [Accessed: 06.06.2017].

2. European Society of Cardiology (ESC), 2016 ESC Guidelines for the

diagnosis and treatment of acute and chronic heart failure, 2016 [Accessed:

06.06.2017].

3. Krum H, Tonkin AM, Currie R, Djundjek R, Johnston CI. Chronic heart failure

in Australian general practice. The Cardiac Awareness Survey and Evaluation

(CASE) Study. The Medical Journal of Australia. 2001 May;174(9):439-44.

4. Phillips SM, Tofler GH, Marton RL. Barriers to diagnosing and managing heart

failure in primary care. The Medical Journal of Australia. 2004 Jul

19;181(2):78-81.

14. The Impact of a Senior Clinical Pharmacist’s Interventions on Patient Care–A Single-Centre Prospective National Health Service

Study across Neurology and Nephrology. Clarissa Captur, Senior Clinical Pharmacist, Dr Gabriella Captur, Dr Norbert Vella,

Prof Emanuel Farrugia, Mater Dei Hospital, Msida, Malta, Europe.

Background

Clinical pharmacy interventions have been shown to optimise therapeutic outcomes

for patients in conjunction with other health-care professionals1,2. The percentage of

hospital pharmacists who regularly log their interventions varies from 50 to 72%

across countries1-4 with no difference by specialty2. Clinical pharmacists with

postgraduate qualifications seem to document significantly more interventions

compared to those without5 and they contribute more interventions5.

Aim

To quantitatively measure the impact of a senior clinical pharmacist’s contribution to

consultant-led neurology and nephrology ward rounds.

Method

This was a prospective single-centre study conducted in a European tertiary care

centre. HanDBase Desktop 3.0 was used to document the interventions carried out

during a 12-month period by a single senior clinical pharmacist with >10 years

experience in the field and post-graduate subspecialty qualifications. All interventions

were logged in real-time and on site (during the ward round) and subsequently batch

inputted into the information governance-secure database on a daily basis.

Results

6,390 drug therapy problems were discovered (Figure 1).

Figure 1 – Drug Therapy Problems.

4,763 treatment reviews were conducted. 1,464 treatment clarification procedures

were performed of which 26% dealt with incomplete treatment and 21% dealt with

unnecessary treatment. Collectively these interventions benefited the quality of

clinical care delivered to a total of 62% patients attending the. A significant number

of interventions resulted in the avoidance of patient harm (19% prescribing errors,

1% missed treatment, 1% administration error, 0% contraindications).

Conclusion

The interventions performed by a senior clinical pharmacist during consultant-led

nephrology and neurology ward rounds substantially benefit patient care and

importantly, they prevent patient harm making the case for each National Health

Service framework to integrate senior clinical pharmacists into the multi-disciplinary

care team.

References

1. Youngmee K, Gregory S. Pharmacist intervention documentation in US health

care systems. Hospital Pharmacist;2003;38:1141-1147.

2. Society of Hospital Pharmacists of Australia Committee of Speciality Practice in

Clinical Pharmacy, Dooley et al. SHPA standards of practice for clinical pharmacy.

Journal of Pharmacy Practice Respiratory;2005;35:122-146.

3. Pedersen CA, Schneider PJ, et al. ASHP national survey of pharmacy practice in

acute care settings: Monitoring, patient education, and wellness – 2000. Amercian

Journal Health System Pharmacy;2000;57:2171-2187.

4. Pederson CA, Schneider PJ, Santell JP. ASHP national survey of pharmacy

practice in hospital settings: Prescribing and transcribing – 2001. American Journal

Health System Pharmacy;2001;58:2251-2266.

5. Al-Jedai A, Nurgat ZA. Electronic Documentation of Clinical Pharmacy

Interventions in Hospitals. Data Mining Applications in Engineering and Medicine;

2012;7:159-178.

Statement: Ethics approval was not required for any part of this study.

15. The Barnet Asthma Step-down Guideline – Simplifying and Optimising Asthma Treatment Step-down for Prescribers