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This article outlines the purchasing process for personal protective equipment that was established for Health and Social Care in Northern Ireland in response to the outbreak of coronavirus disease 2019. The Business Services Organisation Procurement and Logistics Service, who are the sole provider of goods and services for Health and Social Care organisations, was faced with an unprecedented demand for personal protective equipment in response to the coronavirus disease 2019 pandemic. The usual procurement process was further complicated by changing messages within guidelines which resulted in confusion and anxiety when determining whether or not a product would meet the required safety guidance and was therefore suitable for purchase. In order to address these issues in a rapidly changing and escalating scenario the Department of Health asked the Business Services Organisation Procurement and Logistics Service to work with the Medicines Optimisation Innovation Centre to maximise the availability of personal protective equipment whilst ensuring that it met all requisite quality and standards. A process was implemented whereby the Medicines Optimisation Innovation Centre validated all pertinent essential documentation relating to products to ensure that all applicable standards were met, with the Business Services Organisation Procurement and Logistics Service completing all procurement due diligence tasks in line with both normal and coronavirus disease 2019 emergency derogations. It is evident from the data presented that whilst there were a significant number of potential options for supply, a large proportion of these were rejected due to failure to meet the quality assurance criteria. Thus, by the process that was put in place, a large number of unsuitable products were not purchased and only those that met extant standards were approved.

Whilst attention has been paid within the literature to examining potentially inappropriate prescribing (PIP) for older adults in a variety of care settings, less is known about the extent within intermediate care. Furthermore, few studies have examined the utility of clinical pharmacist involvement in this care context.Determine the prevalence of PIP in intermediate care (IC) settings in Northern Ireland (NI), explore the utility of a novel pharmacist case management model at reducing PIP and to examine the association with subsequent healthcare utilisation.Secondary analysis of prospective data (N = 532) collected during a medicines optimisation pharmacist case management model in three intermediate care sites in NI. Independent prescriber pharmacists delivered the intervention. Variability in Medication Appropriateness Index score change (ΔMAI) from admission to discharge was examined using multivariate linear regression analysis. Multivariate logistic and Poisson regressions were used to examine the association between ΔMAI and likelihood and numbers of unplanned hospital readmissions within 30 and 90 days of IC discharge.PIP was highly prevalent (89.5%) at baseline with significant reductions in MAI score achieved from admission (Median = 14) to discharge (Median = 0) (Z = -18.28, p .001). The prevalence of PIP at discharge was 7.8%. No relationship was observed between ΔMAI score and unplanned hospital readmission. Those who received at least one educational intervention were less likely to be readmitted within 30 days of IC discharge (OR = 0.15, 95% CI 0.03, 0.71, p .001). Baseline healthcare utilisation consistently predicted healthcare utilisation post-IC discharge.Drug-related problems persist for many older adults following acute care discharge and intermediate care may provide an ideal location for medicines optimisation interventions.

Medicines optimisation for those with respiratory conditions can have a significant impact on clinical outcomes and substantial efficiency gains for health care. Consultant pharmacists are experts working at the top of their specialism in four main pillars of practice, namely clinical care, leadership, education and training, and research and development. A consultant respiratory pharmacist has recently been appointed at a large Health and Social Care Trust in Northern Ireland to provide expert care and clinical leadership for the medicines optimisation agenda with regards to respiratory care in Northern Ireland. Alongside clinical practice, leadership, and service development, emphasis will be placed on monitoring and evaluating the work of the consultant respiratory pharmacist with a view to gathering the necessary evidence to support the case for further investment in such consultant pharmacist posts in the region. This short communication article outlines some of the clinical and economic factors associated with the decisions to invest in the consultant pharmacist model of care in Northern Ireland

Background This study assessed the pharmacist role in an 80 bed residential care unit by: Quantifying the number and type of pharmacist interventions made and their acceptance rate.Assessing impact of pharmacist interventions on patient care.Assessing staff attitudes towards the clinical pharmacist service. Methods This was a non-blinded, non-comparative evaluation of the existing clinical pharmacist service in the unit. All residents were included. All pharmacist interventions over a 10-week period were recorded, then graded according to the Eadon scale1 by a consultant gerontologist and an experienced pharmacist to assess their impact on patient care. Results There were 615 pharmacist interventions. The most common interventions were: Drug Therapy Review, 34% (n=209) Technical Prescription, 26.5% (n=163) Administration, 15.3% (n=94) Drug Interaction, 10.4% (n=64) Medication Reconciliation, 8.5% (n=52) 98% (n=596) of interventions were rated as having significance to patient care, of which: 48.4% (n=298) and 41.8% (n=257) of the interventions rated as ‘significant and resulting in an improvement in the standard of care’1% (n=6) and 0.5% (n=3) rated as ‘very significant and preventing harm’. There was a statistically significant agreement between the evaluators, κw = 0.231 (95% CI, 0.156 to 0.307), p < .0005. The strength of agreement was fair. Of interventions requiring acceptance by medical team (n=335), 89.9% (n=301) were accepted. 95% (n=36) of staff who responded agreed or strongly agreed that improved patient safety resulted from the pharmacist’s involvement in multidisciplinary medication reviews. Over 92% (n=35) agreed or strongly agreed that their experience of the pharmacist was positive. Conclusion The pharmacist has an important role in our residential care unit. Their involvement in the medicines optimisation process positively impacts patient outcomes and prevents harm. Staff perceived a positive impact of the clinical pharmacist service provided on patient care and patient safety.

Purpose: Use of antibiotics can give rise to the selection of resistant bacteria. It remains unclear whether antibiotic use in primary care can influence bacterial resistance incidence in patients when hospitalised. The aim of this study is to explore the impact of prior community antibiotic usage on hospital-detected multidrug-resistant Gram-negative (MRGN) incidence rate. Methods: This pharmacoepidemiological study was case–control in design, and was carried out in the Antrim Area Hospital (N. Ireland) in two phases. In phase 1, the controls were matched according to: age, gender, admission ward, date of admission, and age-adjusted Charlson co-morbidity index score. During the second phase, controls were selected randomly from the total population of admissions to the hospital over the 2-year study period. Results: In phase 1, multivariate analysis revealed that prior exposure to the second- and third-generation cephalosporins (p = 0.004) and fluoroquinolones (p = 0.023) in primary care was associated with an increased likelihood of MRGN detection in inpatients. In phase 2, an independent relationship between an increased risk of identification of MRGN, while hospitalised was associated with: prolonged hospitalisation (p < 0.001), being elderly (p < 0.001), being female (p = 0.007), and having genitourinary disease (p < 0.001). Conclusion: This study provides clear evidence which supports the need to optimise antibiotic use in primary care to help reduce MRGN incidence in hospitalised patients.

Background: During the COVID-19 pandemic, the scarcity of resources has necessitated triage of critical care for patients with the disease. In patients aged 65 years and older, triage decisions are regularly based on degree of frailty measured by the Clinical Frailty Scale (CFS). However, the CFS could also be useful in patients younger than 65 years. We aimed to examine the association between CFS score and hospital mortality and between CFS score and admission to intensive care in adult patients of all ages with COVID-19 across Europe. Methods: This analysis was part of the COVID Medication (COMET) study, an international, multicentre, retrospective observational cohort study in 63 hospitals in 11 countries in Europe. Eligible patients were aged 18 years and older, had been admitted to hospital, and either tested positive by PCR for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or were judged to have a high clinical likelihood of having SARS-CoV-2 infection by the local COVID-19 expert team. CFS was used to assess level of frailty: fit (CFS 1–3), mildly frail (CFS 4–5), or frail (CFS 6–9). The primary outcome was hospital mortality. The secondary outcome was admission to intensive care. Data were analysed using a multivariable binary logistic regression model adjusted for covariates (age, sex, number of drugs prescribed, and type of drug class as a proxy for comorbidities). Findings: Between March 30 and July 15, 2020, 2434 patients (median age 68 years [IQR 55–77]; 1480 [61%] men, 954 [30%] women) had CFS scores available and were included in the analyses. In the total sample and in patients aged 65 years and older, frail patients and mildly frail patients had a significantly higher risk of hospital mortality than fit patients (total sample: CFS 6–9 vs CFS 1–3 odds ratio [OR] 2·71 [95% CI 2·04–3·60], p4–5 vs CFS 1–3 OR 1·54 [1·16–2·06], p=0·0030; age ≥65 years: CFS 6–9 vs CFS 1–3 OR 2·90 [2·12–3·97], p4–5 vs CFS 1–3 OR 1·64 [1·20–2·25], p=0·0020). In patients younger than 65 years, an increased hospital mortality risk was only observed in frail patients (CFS 6–9 vs CFS 1–3 OR 2·22 [1·08–4·57], p=0·030; CFS 4–5 vs CFS 1–3 OR 1·08 [0·48–2·39], p=0·86). Frail patients had a higher incidence of admission to intensive care than fit patients (CFS 6–9 vs CFS 1–3 OR 1·54 [1·21–1·97], p=0·0010), whereas mildly frail patients had a lower incidence than fit patients (CFS 4–5 vs CFS 1–3 OR 0·71 [0·55–0·92], p=0·0090). Among patients younger than 65 years, frail patients had an increased incidence of admission to intensive care (CFS 6–9 vs CFS 1–3 OR 2·96 [1·98–4·43], p4–5 vs CFS 1–3 OR 0·93 [0·63–1·38], p=0·72). Among patients aged 65 years and older, frail patients had no significant difference in the incidence of admission to intensive care compared with fit patients (CFS 6–9 vs CFS 1–3 OR 1·27 [0·92–1·75], p=0·14), whereas mildly frail patients had a lower incidence than fit patients (CFS 4–5 vs CFS 1–3 OR 0·66 [0·47–0·93], p=0·018). Interpretation: The results of this study suggest that CFS score is a suitable risk marker for hospital mortality in adult patients with COVID-19. However, treatment decisions based on the CFS in patients younger than 65 years should be made with caution. Funding: LOEY Foundation.

International audience; An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Objectives The main aim was to develop a process to estimate critical care drug requirements to robustly inform regional procurement planning and preparedness in response to the COVID-19 pandemic. The objectives were to identify critical care drugs required, obtain patient usage data and consider current regional practice to establish the requirement. Method Health and Social Care (HSC) Trusts across Northern Ireland (NI) identified critical care drugs required and an estimation of average daily usage data. The Microsoft Excel database was constructed to compile Trust data and establish regional requirement. The database was refined further according to real-world data from NI HSC Trusts, Intensive Care National Audit and Research Centre report on COVID-19 in critical care, daily regional COVID-19 figures and other available National data. Components of a tool originally developed for H1N1 and updated for COVID-19 were adapted to reflect the NI context and used in the regional database. The database was clinically reviewed to ensure that it accurately reflected current regional practice given the evolving nature of the pandemic. Results The critical care drugs required in the pandemic, usage data and current regional practice were identified to establish requirement. A regional database was constructed and used to produce a model for calculating approximate critical drug requirements. The model was used to map critical drug requirements to available stock in Trusts and wholesalers/suppliers, enabling the identification of treatment capacity for these medicines regionally, both currently and for projected surges. Data have also been used in the preparation of weekly regional situation reports provided to both the HSC Board and the Department of Health. Conclusion The process developed is a robust approach to assist in informing regional critical care drug requirements in response to the COVID-19 pandemic. Further application has been demonstrated in regional procurement planning and preparedness.

Background There is a major drive within healthcare to reduce patient readmissions, from patient care and cost perspectives. Pharmacist-led innovations have been demonstrated to enhance patient outcomes. Objective To assess the impact of a post-discharge, pharmacist-led medicines optimisation clinic on readmission parameters. Assessment of the economic, clinical and humanistic outcomes were considered. Setting Respiratory and cardiology wards in a district general hospital in Northern Ireland. Method Randomised, controlled trial. Blinded random sequence generation; a closed envelope-based system, with block randomisation. Adult patients with acute unplanned admission to medical wards subject to inclusion criteria were invited to attend clinic. Analysis was carried out for intention-to-treat and per-protocol perspectives. Main Outcome Measure 30-day readmission rate. Results Readmission rate reduction at 30 days was 9.6% (P = 0.42) and the reduction in multiple readmissions over 180-days was 29.1% (P = 0.003) for the intention-to-treat group (n = 31) compared to the control group (n = 31). Incidence rate ratio for control patients for emergency department visits was 1.65 (95% CI 1.05–2.57, P = 0.029) compared with the intention-to-treat group. For unplanned GP consultations the equivalent incident rate ratio was 2.00 (95% CI 1.18–3.58, P = 0.02). Benefit to cost ratio in the intention-to-treat and per-protocol groups was 20.72 and 21.85 respectively. Patient Health Related Quality of Life was significantly higher at 30-day (P P P = 0.036) time points. A positive impact was also demonstrated in relation to patient beliefs about their medicines and medication adherence. Conclusion A pharmacist-led post-discharge medicines optimisation clinic was beneficial from a patient care and cost perspective.

Background To assess antimicrobial prescribing in a Northern Ireland hospital (Antrim Area Hospital (AAH)) and compare them with those of a hospital in Jordan (Specialty Hospital). Methods Using the Global-PPS approach, the present study surveyed patients admitted to the hospital in 2015, the prescribed antibiotics, and a set of quality control indicators related to antibiotics. Results Ultimately, 444 and 112 inpatients in the AAH and the Specialty Hospital, respectively, were surveyed. For the medical group, 165 inpatients were prescribed 239 antibiotics in the AAH, while 44 patients in the Specialty Hospital were prescribed 65 antibiotics. In relation to the surgical group, 34 inpatients treated for infection were prescribed 66 antibiotics in the AAH, while 41 patients in the Specialty Hospital treated for infection were prescribed 56 antibiotics. For the medical patients, the most frequently prescribed antibiotics in the AAH were a combination of penicillins (18.8%) and penicillins with extended spectrum (18.8%). For the surgical patients, the most frequently prescribed antibiotics in the AAH were imidazole derivatives (24.2%). For the medical and surgical patients in the Specialty Hospital, the most frequently prescribed antibiotics were third-generation cephalosporins (26.2 and 37.5%, respectively). In medical patients, compliance to guidelines was 92.2% in the Specialty Hospital compared to 72.0% in the AAH (p

AIMS Inappropriate use of antibiotics is one of the most important factors contributing to the emergence of drug resistant pathogens. The purpose of this study was to measure the clinical impact of antimicrobial stewardship programme (ASP) interventions on hospitalized patients at the Intensive care unit at Palestinian Medical Complex. METHODS A prospective audit with intervention and feedback by ASP team within 48-72 h of antibiotic administration began in September 2015. Four months of pre-ASP data were compared with 4 months of post-ASP data. Data collected included clinical and demographic data; use of antimicrobials measured by defined daily doses, duration of therapy, length of stay, readmission and all-cause mortality. RESULTS Overall, 176 interventions were made the ASP team with an average acceptance rate of 78.4%. The most accepted interventions were dose optimization (87.0%) followed by de-escalation based on culture results with an acceptance rate of 84.4%. ASP interventions significantly reduces antimicrobial use by 24.3% (87.3 defined daily doses/100 beds vs. 66.1 defined daily doses/100 beds P

Worldwide, hundreds of thousands of healthcare acquired infections (HAIs) are reported each year. Contamination of hospitals is a source of, and allows dissemination of HAIs. In healthcare settings one of the major vectors of contamination is healthcare workers’ uniforms. As surfaces become contaminated, bacteria can then be contacted by patients or staff who may indirectly spread bacteria to patients. Direct and indirect spread of bacteria could result in infection of patients and increased infection rates. Further consequences include increased levels of antibiotic use and costs. A pilot study was conducted at Antrim Area Hospital, Northern Health and Social Care Trust. 100 pre-shift and 100 post-shift healthcare workers’ uniforms were assessed for Staphylococcus aureus and Enterococcus spp. isolates. We found increased levels of antibiotic resistant S. aureus and Enterococcus spp. contamination on post-shift uniforms compared to zero to minimal contamination of pre-shift uniforms. A biobank of isolates was subsequently characterised for antibiotic sensitivity using European Union Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines – 51 % of S. aureus isolates were classed multi-drug resistant. Genomic diversity was assessed using Random Amplification of Polymorphic DNA (RAPD) – high levels of similarity was found amongst isolates. As one means of reducing uniform bioburden, we conducted analysis of a novel surface-active organisilane disinfectant named Goldshield (GS). GS was marketed as a long lasting antimicrobial prevent (re)contamination. GS technology displayed bactericidal, sporicidal and anti-biofilm properties in laboratory testing providing rationale for an intervention where GS could be incorporated into hospital laundry and assessed for potential use in infection control.

People generally need more support as they grow older to maintain healthy and active lifestyles. Older people living with chronic conditions are particularly dependent on healthcare services. Yet, in an increasingly digital society, there is a danger that efforts to drive innovations in eHealth will neglect the needs of those who depend on healthcare the most—our ageing population. The SHAPES (Smart and Healthy Ageing through People Engaging in Supportive Systems) Innovation Action aims to create an open European digital platform that facilitates the provision of meaningful, holistic support to older people living independently. A pan-European pilot campaign will evaluate a catalogue of digital solutions hosted on the platform that have been specifically adapted for older people. ‘Medicines control and optimisation’ is one of seven themes being explored in the campaign and will investigate the impact of digital solutions that aim to optimise medicines use by way of fostering effective self-management, while facilitating timely intervention by clinicians based on remote monitoring and individualised risk assessments powered by artificial intelligence. If successful, the SHAPES Innovation Action will lead to a greater sense of self-sufficiency and empowerment in people living with chronic conditions as they grow older.

Balancing access to antibiotics with the control of antibiotic resistance is a global public health priority. At present, antibiotic stewardship is informed by a ‘use it and lose it’ principle, in which antibiotic use by the population is linearly related to resistance rates. However, theoretical and mathematical models suggest that use–resistance relationships are nonlinear. One explanation for this is that resistance genes are commonly associated with ‘fitness costs’ that impair the replication or transmissibility of the pathogen. Therefore, resistant genes and pathogens may only gain a survival advantage where antibiotic selection pressures exceed critical thresholds. These thresholds may provide quantitative targets for stewardship—optimizing the control of resistance while avoiding over-restriction of antibiotics. Here, we evaluated the generalizability of a nonlinear time-series analysis approach for identifying thresholds using historical prescribing and microbiological data from five populations in Europe. We identified minimum thresholds in temporal relationships between the use of selected antibiotics and incidence rates of carbapenem-resistant Acinetobacter baumannii (Hungary), extended-spectrum β-lactamase-producing Escherichia coli (Spain), cefepime-resistant E. coli (Spain), gentamicin-resistant Pseudomonas aeruginosa (France) and methicillin-resistant Staphylococcus aureus (Northern Ireland) in different epidemiological phases. Using routinely generated data, our approach can identify context-specific quantitative targets for rationalizing population antibiotic use and controlling resistance. Prospective intervention studies that restrict antibiotic consumption are needed to validate these thresholds., G.K. was supported by a Bolyai Research Scholarship of the Hungarian Academy of Sciences. T.L. was supported by the Wellcome Trust. J.R.B. and P.R. received funding for research from Plan Nacional de I+D+i 2013–2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Economía, Industria y Competitividad, Spanish Network for Research in Infectious Diseases (RD16/0016/0001), co-financed by European Development Regional Fund ‘A way to achieve Europe’, Operative Programme Intelligent Growth 2014–2020.

This quasi-experimental study investigated the effect of an antibiotic cycling policy based on time-series analysis of epidemiologic data, which identified antimicrobial drugs and time periods for restriction. Cyclical restrictions of amoxicillin/clavulanic acid, piperacillin/tazobactam, and clarithromycin were undertaken over a 2-year period in the intervention hospital. We used segmented regression analysis to compare the effect on the incidence of healthcare-associated Clostridioides difficile infection (HA-CDI), healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA), and new extended-spectrum β-lactamase (ESBL) isolates and on changes in resistance patterns of the HA-MRSA and ESBL organisms between the intervention and control hospitals. HA-CDI incidence did not change. HA-MRSA incidence increased significantly in the intervention hospital. The resistance of new ESBL isolates to amoxicillin/clavulanic acid and piperacillin/tazobactam decreased significantly in the intervention hospital; however, resistance to piperacillin/tazobactam increased after a return to the standard policy. The results question the value of antibiotic cycling to antibiotic stewardship.

Use of antibiotics can give rise to the selection of resistant bacteria. It remains unclear whether antibiotic use in primary care can influence bacterial resistance incidence in patients when hospitalised. The aim of this study is to explore the impact of prior community antibiotic usage on hospital-detected multidrug-resistant Gram-negative (MRGN) incidence rate.This pharmacoepidemiological study was case-control in design, and was carried out in the Antrim Area Hospital (N. Ireland) in two phases. In phase 1, the controls were matched according to: age, gender, admission ward, date of admission, and age-adjusted Charlson co-morbidity index score. During the second phase, controls were selected randomly from the total population of admissions to the hospital over the 2-year study period.In phase 1, multivariate analysis revealed that prior exposure to the second- and third-generation cephalosporins (p = 0.004) and fluoroquinolones (p = 0.023) in primary care was associated with an increased likelihood of MRGN detection in inpatients. In phase 2, an independent relationship between an increased risk of identification of MRGN, while hospitalised was associated with: prolonged hospitalisation (p 0.001), being elderly (p 0.001), being female (p = 0.007), and having genitourinary disease (p 0.001).This study provides clear evidence which supports the need to optimise antibiotic use in primary care to help reduce MRGN incidence in hospitalised patients.

AIMS: To implement pharmacist-led, postdischarge telephone follow-up (TFU) intervention and to evaluate its impact on rehospitalization parameters in polypharmacy patients, via comparison with a well-matched control group.METHOD: Pragmatic, prospective, quasi-experimental study. Intervention patients were matched by propensity score techniques with a control group. Guided by results from a pilot study, clinical pharmacists implemented TFU intervention, added to routine integrated medicines management service.RESULTS: Using an intention to treat approach, reductions in 30- and 90-day readmission rates for intervention patients compared with controls were 9.9% [odds ratio = 0.57; 95% confidence interval (CI): 0.36-0.90; P < 0.001] and 15.2% (odds ratio = 0.53; 95% CI: 0.36-0.79; P = 0.021) respectively. Marginal mean time to readmission was 70.9 days (95% CI: 66.9-74.9) for intervention group compared with 60.1 days (95% CI: 55.4-64.7) for controls. Mean length of hospital stay compared with control was (8.3 days vs. 6.7 days; P < 0.001). Benefit: cost ratio for 30-day readmissions was 29.62, and 23.58 for 90-day interval. Per protocol analyses gave more marked improvements. In intervention patients, mean concern scale score, using Beliefs about Medicine Questionnaire, was reduced 3.2 (95% CI: -4.22 to -2.27; P < 0.001). Mean difference in Medication Adherence Report Scale was 1.4 (22.7 vs. 24.1; P < 0.001). Most patients (83.8%) reported having better control of their medicines after the intervention.CONCLUSIONS: Pharmacist-led postdischarge structured TFU intervention can reduce 30- and 90-day readmission rates. Positive impacts were noted on time to readmission, length of hospital stay upon readmission, healthcare costs, patient beliefs about medicines, patient self-reported adherence and satisfaction.

Antimicrobial resistance is a limiting factor for the success of the treatment of infectious diseases and is associated with increased morbidity and cost. The present study aims to evaluate prescribing patterns of antimicrobials and quantify progress in relation to targets for quality improvement in the prescription of antimicrobials in Northern Ireland’s secondary care sector using three repetitive point prevalence surveys (PPS) over a 6-year period: the European Surveillance of Antimicrobial Consumption (ESAC-PPS) in 2009 and 2011 and the GlobalPPS on Antimicrobial Consumption and Resistance in 2015. Out of 3605 patients surveyed over the three time points, 1239 (34.4%) were treated with an antibiotic, the most frequently prescribed antibiotic groups were a combination of penicillins, including β-lactamase inhibitors. Compliance with hospital antibiotic policies in 2009, 2011 and 2015 were 54.5%, 71.5% and 79.9%, respectively. Likewise, an indication for treatment was recorded in patient notes 88.5%, 87.7% and 90.6% in 2009, 2011 and 2015, respectively, and surgical prophylactic antibiotic prescriptions for >24 h was 3.9%, 3.2% and 0.7% in 2009, 2011 and 2015, respectively. Treatment based on biomarker data was used in 61.5% of cases. In conclusion, a general trend in the improvement of key antimicrobial-related quality indicators was noted. The PPS tool provided a convenient, inexpensive surveillance system of antimicrobial consumption and should be considered an essential component to establish and maintain informed antibiotic stewardship in hospitals., peer-reviewed

Objective The objective of this review was to assess the improvement in medicines processes in Northern Ireland focusing mainly on secondary care and at the interface with primary care and also to consider the benefits of enabling technologies for the system. Methods The review was undertaken by examining all of the publications that had been produced together with relevant context articles that framed and supported the requisite process changes together with a synopsis of relevant enabling technologies that were devised. Key outputs were summarised and incorporated into the system review. Results The optimisation of the medicines process has led to benefits to patients in terms of morbidity and mortality in addition to a reduction in healthcare resource utilisation. Key findings include reduced length of stay, reduced readmission rates, improved Medicines Appropriateness Index, improved Medicines Administration Error rate, positive impact on Risk Adjusted Mortality Index and improved communication across the primary/secondary care interface. Enabling technology solutions were also implemented. Conclusions The journey from medicines management to optimisation has resulted in significant improvements in the quality and safety of medicines yielding health gain and economy and a return on investment of £5–8 for each £1 invested. The complementary role of pharmacy in the multidisciplinary team has been identified and evidenced. The next steps will be to further integrate with primary care and deliver improvements in medicines processes in that sector together with requisite enabling technologies.

Introduction & Practice Change: In 2012, the Northern Health and Social Care Trust (NHSCT) implemented consultant pharmacist led trust outreach medicines optimisation clinics for care home patients. This model required the consultant pharmacist to conduct clinics either alone or in collaboration with a consultant geriatrician with recommendations being communicated to General Practitioners (GPs) via a letter. This service resulted in a 14% reduction in Emergency Department (ED) admissions together with improved appropriateness of prescribing and drug cost savings1. Results (2012-2014) indicated the pharmacist working alone produced similar outcomes as to when working together with the geriatrician; the decision was therefore made for pharmacists to conduct clinics alone and to refer complex patients to a medical specialist only when deemed necessary. Aim: The aim of this work is to refine the medicines optimisation care home model and reproduce it in another trust, thereby informing the potential to roll out this new pharmacy service throughout care homes in Northern Ireland. Target Population: Patients aged ≥65 years residing in residential and nursing homes (care homes). Timeline: In August 2015 two older people specialist independent prescribing pharmacists were recruited into the NHSCT service under the mentorship of the consultant pharmacist. The Western Health and Social Care Trust (WHSCT) recruited two similar full time pharmacists who have delivered the same consultant pharmacist led model to care homes since September 2015. Data collection for patients seen over a 12-month period and followed up for 90 days is ongoing with full results to be reported early 2017. Highlights: Interim results (February 2016) revealed improved appropriateness of prescribing [measured via the medication appropriateness index (MAI)2] with associated annual drug cost savings estimated at £273k to £382k across the two trusts representing an ‘invest to save’ return of £1.51 - £2.12 per £1 invested in drug cost savings alone. Post clinic healthcare resource usage is being measured and an economic model is being developed to quantify the impact of the pharmacy service on these; interim analysis suggests reduced attendance at hospital ED and decreased GP callouts. Sustainability/Transferability: Preliminary evaluation of the service suggests it is both reproducible and sustainable. Discussion/Lessons Learnt: The WHSCT pharmacists tested different GP communication models where interventions may be actioned via letter, teleconference or direct access into GP systems. The method of communicating recommended clinical interventions between the trust pharmacist and GP can vary depending upon the size and location of the care home and the wishes of the GP responsible for patient care. Conclusion: Consultant pharmacist led medicines optimisation trust outreach services for care homes are reproducible with positive clinical and economic outcomes achievable when transferring the service into another geographical area. References: 1- McKee H et al. Nursing Home Outreach Clinics show an improvement in patient safety and reduction in hospital admissions in residents with chronic conditions. Accepted for Publication on 14.04.2016 and In Press, European Journal for Person Centered Healthcare. 2-Hanlon JT et al. A method for determining drug therapy appropriateness. Journal of Clinical Epidemiology, 1992; 45 (10): 1045-51.

Introduction:Medication related problems following hospital discharge are claimed to be a major cause of readmission,morbidity and mortality(Mistiaen and Poot,2006 ;Hugtenburg et al.,2014).To date studies at this transition of care have shown mixed results regarding the benefits of post discharge follow up(Wong et al.,2008,Leppin et al., 2014)Thus further work in this aspect of medicines optimisation would be of value.Objective: To design and implement pharmacist led post-discharge interventions and analyse their impact on rehospitalisation parameters for patients who received ten or more medicines.Method: This study was designed as a mixed quasi-experimental pilot. Intervention patients were randomised to receive the designed prospective interventions either by hospital or community pharmacists; the rehospitalisation parameters were compared with matched control patients. Primary outcome was the 30 day readmission rate. Secondary out comes were the 180 day readmission rate, length of hospital stay on the first readmission, time to first readmission, number, type and potential impact of pharmacist interventions, communication evaluation across the secondary/primary care interface, and assessments of intervention patient’s adherence, beliefs about medicines and satisfaction.Results: 30 day readmission rate for patients who received hospital pharmacist interventions was (8.7%) compared with (71.0%) for its matched control patients (odds ratio [OR]= 0.04 [95%CI, 0.01-0.18], P=0.001), for community group patients it was (28.0%) compared with (69.3%) for its matched control patients (OR= 0.17 [95%CI, 0.06 -0.47], P

AIMS: Inappropriate use of antibiotics is one of the most important factors contributing to the emergence of drug resistant pathogens. The purpose of this study was to measure the clinical impact of antimicrobial stewardship programme (ASP) interventions on hospitalized patients at the Intensive care unit at Palestinian Medical Complex. METHODS: A prospective audit with intervention and feedback by ASP team within 48–72 h of antibiotic administration began in September 2015. Four months of pre‐ASP data were compared with 4 months of post‐ASP data. Data collected included clinical and demographic data; use of antimicrobials measured by defined daily doses, duration of therapy, length of stay, readmission and all‐cause mortality. RESULTS: Overall, 176 interventions were made the ASP team with an average acceptance rate of 78.4%. The most accepted interventions were dose optimization (87.0%) followed by de‐escalation based on culture results with an acceptance rate of 84.4%. ASP interventions significantly reduces antimicrobial use by 24.3% (87.3 defined daily doses/100 beds vs. 66.1 defined daily doses/100 beds P

Ghaith M Al-Taani,1 Sayer I Al-Azzam,2 Karem H Alzoubi,2 Feras W Darwish Elhajji,3 Michael G Scott,4 Hamzah Alfahel,5 Mamoon A Aldeyab6 1Department of Pharmacy Practice, Faculty of Pharmacy, Yarmouk University, 2Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, 3Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan; 4Medicines Optimisation Innovation Centre, Pharmacy and Medicines Management Centre, Northern Health and Social Care Trust, Ballymena, Northern Ireland, UK; 5General and Specialized Surgery Department, Faculty of Medicine, Hashemite University, Zarqa, Jordan; 6School of Pharmacy and Pharmaceutical Science, University of Ulster, Coleraine, County Londonderry, UK Objective: Drug-related problems (DRPs) are considered a serious, expensive, and important undesirable complication of health care. However, as current health care resources are limited, pharmacist DRP services cannot be provided to all patients. Using a modeling approach, we aimed to identify risk factors for DRPs so that patients for DRP-reduction services can be better identified. Methods: Patients with diabetes from outpatient clinics from five key university-affiliated and public hospitals in Jordan were assessed for DRPs (drug without an indication, untreated indication, and drug efficacy problems). Potential risk factors for DRPs were assessed. A logistic regression model was used to identify risk factors using a randomly selected, independent, nonoverlapping development (75%) subsample from full dataset. The remaining validation subsample (25%) was reserved to assess the discriminative ability of the model. Results: A total of 1,494 patients were recruited. Of them, 81.2% had at least one DRP. Using the development subsample (n=1,085), independent risk factors for DRPs identified were male gender, number of medications, prescribed gastrointestinal medication, and nonadherence to self-care and non-pharmacological recommendations. Validation results (n=403) showed an area under the receiver operating characteristic curve of 0.679 (95% confidence interval=0.629–0.720); the model sensitivity and specificity values were 65.4% and 63.0%, respectively.Conclusion: Within the outpatient setting, the results of this study predicted DRPs with acceptable accuracy and validity. Such an approach will help in identifying patients needing pharmacist DRP services, which is an important first step in appropriate intervention to address DRPs. Keywords: medication-related problems, drug-related problems, pharmaceutical care, outpatient, diabetes&nbsp

Rationale, aims and objectives This study aimed to determine the value of using a mix of clinical pharmacy data and routine hospital admission spell data in the development of predictive algorithms. Exploration of risk factors in hospitalized patients, together with the targeting strategies devised, will enable the prioritization of clinical pharmacy services to optimize patient outcomes. Methods Predictive algorithms were developed using a number of detailed steps using a 75% sample of integrated medicines management (IMM) patients, and validated using the remaining 25%. IMM patients receive targeted clinical pharmacy input throughout their hospital stay. The algorithms were applied to the validation sample, and predicted risk probability was generated for each patient from the coefficients. Risk threshold for the algorithms were determined by identifying the cut-off points of risk scores at which the algorithm would have the highest discriminative performance. Clinical pharmacy staffing levels were obtained from the pharmacy department staffing database. Results Numbers of previous emergency admissions and admission medicines together with age-adjusted co-morbidity and diuretic receipt formed a 12-month post-discharge and/or readmission risk algorithm. Age-adjusted co-morbidity proved to be the best index to predict mortality. Increased numbers of clinical pharmacy staff at ward level was correlated with a reduction in risk-adjusted mortality index (RAMI). Conclusions Algorithms created were valid in predicting risk of in-hospital and post-discharge mortality and risk of hospital readmission 3, 6 and 12 months post-discharge. The provision of ward-based clinical pharmacy services is a key component to reducing RAMI and enabling the full benefits of pharmacy input to patient care to be realized.

Objectives To audit the quality of treatment of lower respiratory tract infections (LRTIs) and urinary tract infections (UTIs) and to identify targets for antibiotic stewardship. Methods The audit involved collecting data on admitted patients, who were diagnosed with LRTIs or UTIs and subsequently received antibiotic treatment (January 2009–April 2009). Key findings The percentage adherence rate for hospital antibiotic policy was 68.6% (24/35). Documentation of the CURB-65 score was found in 80% (16/20) of the patients’ clinical notes, for which 46.2% (6/13) of patients were treated according to their CURB-65 score. The percentages of delayed and missed doses for all antibiotics were 21.7% (254/1171) and 8.6% (101/1171), respectively. The percentage of patients switched from intravenous to oral antibiotics in accordance with the policy was 58.5% (31/53). The mean length of stay for patients switched in line with the guidelines was 6.9 days (range: 2–18 days) compared with 13.2 days (range: 4–28 days) for patients treated with intravenous antibiotics >24 h after the intravenous to oral switch criteria were fulfilled; this equates to on average an extra 6.3 days of hospitalisation (p=0.01). Conclusions The study identified a number of targets for quality improvement including adherence to antibiotic policy, documentation of the CURB-65 score in patients’ notes and treating patients accordingly, addressing the issue of missed and delayed doses, and maintaining adherence to the hospital intravenous-to-oral antibiotic switch policy. The findings suggest that the quality of antibiotic prescribing could be improved by measuring and addressing such performance indicators.

Objectives To determine whether adjusting the denominator of the common hospital antibiotic use measurement unit (defined daily doses/100 bed-days) by including age-adjusted comorbidity score (100 bed-days/age-adjusted comorbidity score) would result in more accurate and meaningful assessment of hospital antibiotic use. Methods The association between the monthly sum of age-adjusted comorbidity and monthly antibiotic use was measured using time-series analysis (January 2008 to June 2012). For the purposes of conducting internal benchmarking, two antibiotic usage datasets were constructed, i.e. 2004-07 (first study period) and 2008-11 (second study period). Monthly antibiotic use was normalized per 100 bed-days and per 100 bed-days/age-adjusted comorbidity score. Results Results showed that antibiotic use had significant positive relationships with the sum of age-adjusted comorbidity score (P = 0.0004). The results also showed that there was a negative relationship between antibiotic use and (i) alcohol-based hand rub use (P = 0.0370) and (ii) clinical pharmacist activity (P = 0.0031). Normalizing antibiotic use per 100 bed-days contributed to a comparative usage rate of 1.31, i.e. the average antibiotic use during the second period was 31% higher than during the first period. However, normalizing antibiotic use per 100 bed-days per age-adjusted comorbidity score resulted in a comparative usage rate of 0.98, i.e. the average antibiotic use was 2% lower in the second study period. Importantly, the latter comparative usage rate is independent of differences in patient density and case mix characteristics between the two studied populations. Conclusions The proposed modified antibiotic measure provides an innovative approach to compare variations in antibiotic prescribing while taking account of patient case mix effects.

SUMMARYThe objective of this study was to evaluate the impact of restricting high-risk antibiotics on methicillin-resistant Staphylococcus aureus (MRSA) incidence rates in a hospital setting. A secondary objective was to assess the impact of reducing fluoroquinolone use in the primary-care setting on MRSA incidence in the community. This was an interventional, retrospective, ecological investigation in both hospital and community (January 2006 to June 2010). Segmented regression analysis of interrupted time-series was employed to evaluate the intervention. The restriction of high-risk antibiotics was associated with a significant change in hospital MRSA incidence trend (coefficient = −0·00561, P = 0·0057). Analysis showed that the intervention relating to reducing fluoroquinolone use in the community was associated with a significant trend change in MRSA incidence in community (coefficient = −0·00004, P = 0·0299). The reduction in high-risk antibiotic use and fluoroquinolone use contributed to both a reduction in incidence rates of MRSA in hospital and community (primary-care) settings.

Objective To determine if the introduction of patient bedside medicine lockers leads to a safer and faster medicine administration round. Methods The undisguised observer technique was utilised to observe the medicine administration round on four wards, two medical wards in Antrim Area Hospital (AAH) and two surgical wards in Causeway Hospital (CH), both before and after the introduction of patient bedside medicine lockers. All non-intravenous medicine administrations during the morning medicines administration round were observed and timed before and after the introduction of the lockers. Medicine administration errors (MAEs), time taken and reasons for delays were recorded and analysed. Results The MAE rate and the time spent on the medicine administration round both decreased after the introduction of patient bedside medicine lockers. The MAE rate dropped from 8.3% to 1.3% (p 0.05), respectively. Conclusions The introduction of patient bedside medicine lockers resulted in safer and faster medicine administration rounds.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • The emergence and spread of bacteria producing extended-spectrum beta-lactamases (ESBLs) has important therapeutic and epidemiologic implications. • A key target for the establishment of hospital antibiotic stewardship is reducing the occurrence of additional antibiotic resistance. • Further research is needed to accumulate supporting evidence that reducing antibiotic use will result in a parallel reduction in antibiotic resistance. WHAT THIS STUDY ADDS • Fluoroquinolone restriction reversed ciprofloxacin resistance in primary and secondary healthcare settings. • Fluoroquinolone restriction reduced ESBL-producing bacteria incidence rates in both the primary and secondary healthcare settings. • This study highlights the value of time-series analysis in designing efficient antibiotic stewardship. AIMS The objective of the present study was to study the relationship between hospital antibiotic use, community antibiotic use and the incidence of extended-spectrum beta-lactamase (ESBL)-producing bacteria in hospitals, while assessing the impact of a fluoroquinolone restriction policy on ESBL-producing bacteria incidence rates. METHODS The study was retrospective and ecological in design. A multivariate autoregressive integrated moving average (ARIMA) model was built to relate antibiotic use to ESB-producing bacteria incidence rates and resistance patterns over a 5 year period (January 2005–December 2009). RESULTS Analysis showed that the hospital incidence of ESBLs had a positive relationship with the use of fluoroquinolones in the hospital (coefficient = 0.174, P= 0.02), amoxicillin-clavulanic acid in the community (coefficient = 1.03, P= 0.03) and mean co-morbidity scores for hospitalized patients (coefficient = 2.15, P= 0.03) with various time lags. The fluoroquinolone restriction policy was implemented successfully with the mean use of fluoroquinolones (mainly ciprofloxacin) being reduced from 133 to 17 defined daily doses (DDDs)/1000 bed days (P < 0.001) and from 0.65 to 0.54 DDDs/1000 inhabitants/day (P= 0.0007), in both the hospital and its surrounding community, respectively. This was associated with an improved ciprofloxacin susceptibility in both settings [ciprofloxacin susceptibility being improved from 16% to 28% in the community (P < 0.001)] and with a statistically significant reduction in ESBL-producing bacteria incidence rates. DISCUSSION This study supports the value of restricting the use of certain antimicrobial classes to control ESBL, and demonstrates the feasibility of reversing resistance patterns post successful antibiotic restriction. The study also highlights the potential value of the time-series analysis in designing efficient antibiotic stewardship.

SUMMARYThe objective of this research was to assess current patterns of hospital antibiotic prescribing in Northern Ireland and to determine targets for improving the quality of antibiotic prescribing. A point prevalence survey was conducted in four acute teaching hospitals. The most commonly used antibiotics were combinations of penicillins including β-lactamase inhibitors (33·6%), metronidazole (9·1%), and macrolides (8·1%). The indication for treatment was recorded in 84·3% of the prescribing episodes. A small fraction (3·9%) of the surgical prophylactic antibiotic prescriptions was for >24 h. The results showed that overall 52·4% of the prescribed antibiotics were in compliance with the hospital antibiotic guidelines. The findings identified the following indicators as targets for quality improvement: indication recorded in patient notes, the duration of surgical prophylaxis and compliance with hospital antibiotic guidelines. The results strongly suggest that antibiotic use could be improved by taking steps to address the identified targets for quality improvement.

Rational, aims and objective The aim of the present study was to compare the ease of use and the capability of four approaches [Medication Appropriateness Index (MAI), the Beers' criteria 2003, the Improved Prescribing in the Elderly Tool (IPET) and Health Plan Employer Data and Information Set (HEDIS)] in assessing changes in medication appropriateness in elderly patients over a period of hospitalization. Methods A retrospective observational study in two hospitals in Northern Ireland using the four measures was undertaken, involving a cohort of 192 patients (aged > 65 years). Medication appropriateness assessments were made at three stages during the patients' hospital ‘journey’, that is, at admission, during their inpatient stay and at discharge. The identifying rates of inappropriate prescribing in elderly patients in hospital used validated screening tools: MAI, the Beers' criteria 2003, the IPET and HEDIS. Results The MAI was the most comprehensive approach but was also the most time consuming to apply. Data derived using the MAI indicated clearly that there was improved medication appropriateness over the three hospital stay stages (P

Rationale, aims and objectives Previous service development work in the area of integrated medicines management (IMM) has demonstrated clear quality improvements in a targeted group of patients within a hospital in Northern Ireland. In order to determine whether this programme could be transferable to routine practice and thereby assess its generalizability, research has been carried out to quantify the health care benefits of incorporating the concept of IMM as routine clinical practice. Method The IMM programme of care was delivered to all eligible patients (subject to inclusion criteria) across two hospital sites in Northern Ireland during normal pharmacy opening hours. All patients were followed up for a period of 12 months from their time of hospital admission. All patient data were collected using the custom-designed Electronic Pharmacist Intervention Clinical System at each stage of their hospital journey, that is, admission, inpatient stay and discharge. Results Patients who received the IMM service benefited from a reduced length of hospital stay on their reference admission (1.42 days; P = 0.020) as well as a reduced length of stay during the first rehospitalization (5.86 days; P = 0.013). There was also a trend of a reduced number of readmissions and a longer time to readmission during the 12-month follow-up period. Potential significant opportunity cost savings were demonstrated as well as a significant improvement in medication appropriateness (discharge vs. reference admission). Conclusions The IMM programme of care has proven to be transferable to routine hospital care within two hospitals in Northern Ireland. It is anticipated that this current research will further inform the development of IMM as routine clinical practice across Northern Ireland and beyond.

Blood cultures have an important role in the diagnosis of serious infections, although contamination of blood cultures (i.e. false-positive blood cultures) is a common problem within the hospital setting. The objective of the present investigation was to determine the impact of the false-positive blood culture results on the following outcomes: length of stay, hotel costs, antimicrobial costs, and costs of laboratory and radiological investigation. A retrospective case-control study design was used in which 142 false-positive blood culture cases were matched with suitable controls (patients for whom cultures were reported as true negatives). The matching criteria included age, comorbidity score and month of admission to the hospital. The research covered a 13-month period (July 2007 to July 2008). The findings indicated that differences in means, between cases and controls, for the length of hospital stay and the total costs were 5.4 days [95% CI (confidence interval): 2.8-8.1 days; P0.001] and £5,001.5 [$7,502.2; 95% CI: £3,283.9 ($4,925.8) to £6,719.1 ($10,078.6); P0.001], respectively. Consequently, and considering that 254 false-positive blood cultures had occurred in the study site hospital over a one-year period, patients with false-positive blood cultures added 1372 extra hospital days and incurred detrimental additional hospital costs of £1,270,381 ($1,905,572) per year. The findings therefore demonstrate that false-positive blood cultures have a significant impact on increasing hospital length of stay, laboratory and pharmacy costs. These findings highlight the need to intervene to raise the standard of blood-culture-taking technique, thus improving both the quality of patient care and resource use.

AIM The aim of the study was to assess current patterns of antibiotic prescribing and the impact of a hospital antibiotic policy on these practices. METHODS The study involved collecting information regarding hospitalized patients utilizing the ESAC audit tool. RESULTS In the study site hospital, the use of the restricted agents was low whilst the use of the non-restricted agents was high. Compliance with the hospital antibiotic guidelines was 70%. DISCUSSION The findings identified monitoring non-restricted antibiotics and compliance with guidelines as targets for quality improvements in our hospital. Point prevalence surveys may offer a simple method of monitoring antibiotic policies, thus, informing antibiotic stewardship.

ACE inhibitors have proven to be effective blood pressure lowering agents with an excellent tolerability profile. The family of these drugs is still expanding, necessitating the definition of selection criteria in order to choose the “right drug”. In this article the ACE inhibitors available in the United Kingdom (UK) are scored by means of the SOJA method. The System of Objectified Judgement Analysis (SOJA) method is a model for rational drug selection. The relevant selection criteria for a certain group of drugs are defined and judged by a panel of experts and each selection criterion is given a relative weight. The more important that a selection criterion is considered, the higher the relative weight that is given to that criterion. The ideal properties for each selection criterion are determined and each drug is scored as a percentage of the score of the ideal drug for all selection criteria. The following selection criteria were used (relative weight): number of formulations (20), number of indications (20), variation in bioavailability (40), interactions (40), trough/peak ratio diastolic blood pressure lowering effect (20), efficacy (250), side-effects (150), dosage frequency (100), documentation (100) and effect on clinical endpoints (260). Ramipril showed the highest score, followed by perindopril, lisinopril and enalapril. The well documented effects on clinically relevant end points, such as cardiovascular morbidity and mortality contributed to the high score for ramipril.

Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen worldwide. A wide range of factors have been suggested to influence the spread of MRSA. The objective of this study was to evaluate the effect of antimicrobial drug use and infection control practices on nosocomial MRSA incidence in a 426-bed general teaching hospital in Northern Ireland.The present research involved the retrospective collection of monthly data on the usage of antibiotics and on infection control practices within the hospital over a 5 year period (January 2000-December 2004). A multivariate ARIMA (time-series analysis) model was built to relate MRSA incidence with antibiotic use and infection control practices.Analysis of the 5 year data set showed that temporal variations in MRSA incidence followed temporal variations in the use of fluoroquinolones, third-generation cephalosporins, macrolides and amoxicillin/clavulanic acid (coefficients = 0.005, 0.03, 0.002 and 0.003, respectively, with various time lags). Temporal relationships were also observed between MRSA incidence and infection control practices, i.e. the number of patients actively screened for MRSA (coefficient = -0.007), the use of alcohol-impregnated wipes (coefficient = -0.0003) and the bulk orders of alcohol-based handrub (coefficients = -0.04 and -0.08), with increased infection control activity being associated with decreased MRSA incidence, and between MRSA incidence and the number of new patients admitted with MRSA (coefficient = 0.22). The model explained 78.4% of the variance in the monthly incidence of MRSA.The results of this study confirm the value of infection control policies as well as suggest the usefulness of restricting the use of certain antimicrobial classes to control MRSA.

Drug selection should be a rational process that embraces the principles of evidence-based medicine. However, many factors may affect the choice of agent. It is against this background that the System of Objectified Judgement Analysis (SOJA) process for rational drug-selection was developed. This article describes how the information on which the SOJA process is based, was researched and processed.

A number of medicine selection methods have been used worldwide for formulary purposes. In Northern Ireland, integrated medicines management is being developed, and related projects have been carried out. This paper deals with the description of the STEPS (Safe Therapeutic Economic Pharmaceutical Selection) programme. The paper outlines the development of STEPS and its application as an element of a cost-effective medicines-management process in Northern Ireland.

Background and objectives: System of Objectified Judgement Analysis (SOJA) is a structured approach to the selection of drugs for formulary inclusion. However, while SOJA is a very important advance in drug selection for formulary purposes, it is hospital based and can only be applied to one indication at a time. In SOJA, cost has been given a primary role in the selection process as it has been included as a selection criterion from the start. Cost may therefore drive the selection of a particular drug product at the expense of other basic criteria such as safety or efficacy. The aims of this study were to use a modified SOJA approach in the selection of ACE inhibitors (ACEIs) for use in a joint formulary that bridges primary and secondary care within a health board in Northern Ireland, and to investigate the potential impact of the joint formulary on prescribing costs of ACEIs in that health board. Methods: The modified SOJA approach involved four phases in sequence: an evidence-based pharmacotherapeutic evaluation of all available ACEI drug entities, a separate safety/risk assessment analysis of products containing agents that exceeded the pharmacotherapeutic threshold, a budget-impact analysis and, finally, the selection of product lines. A comprehensive literature review and expert panel judgement informed the selection of criteria (and their relative weighting) for the pharmacotherapeutic evaluation. The resultant criteria/scoring system was circulated (in questionnaire format) to prescribers and stakeholders for comment. Based on statistical analysis of the latter survey results, the final scoring system was developed. Drug entities that exceeded the evidence threshold were sequentially entered into the second and third phases of the process. Results: Five drug entities (11 currently available in the UK) exceeded the evidence threshold and 22 of 26 submitted product lines containing these drug entities satisfied the safety/risk assessment criteria. Three product lines, each containing a different drug entity, were selected for formulary inclusion after budget impact analysis was performed. The estimated potential annual cost savings for ACEIs (based on estimated annual usage in defined daily doses) for this particular health board was 42%. Conclusion: The modified SOJA approach has a significant contribution to make in containing the costs of ACEIs. Applying modified SOJA as a practical method for all indications will allow the development of a unified formulary that bridges secondary and primary care.

Summary Objective: The present study addresses pharmacy expenditure within a surgical directorate in a UK hospital. The aim of the study was to develop a health care resource group (HRG)-based costing model that can be used to forecast pharmacy expenditure based on surgical casemix. Such a model will be of benefit as an expenditure projection tool at a time when hospitals are developing accelerated operation programmes in an attempt to decrease hospital waiting times. Method: During the period February–April 2000, nursing staff recorded all pharmacy sourced items for each individual operation in the theatres used for general surgery, ENT surgery and gynaecological procedures; each operation was also classified according to its HRG. The associated costs of the items per HRG were identified and the average pharmaceutical cost per HRG calculated and included in the costing model. The model derived costs over the study period were compared with the actual pharmacy expenditure which was obtained from the pharmacy computer system. Finally HRG data for operations carried out in February 2002 were costed using the model for validation purposes. Results: The estimated pharmaceutical cost for surgery items for February–April 2000 was £121 235. This figure was 3·92% over the actual pharmaceutical expenditure as determined from computer records. The February 2002 casemix varied considerably from that of 2000. However, the model estimated pharmaceutical cost of surgery performed in February 2002 (£38 054) was again very similar to the computer logged expenditure (1·09% under the actual expenditure for that period) indicating the robustness of the HRG-based costing approach.

To investigate factors that influence hospital readmissions of elderly patients and to construct a robust hospital readmissions predictive model. Each hospitalised patient was interviewed and medical, demographic and socioeconomic data were obtained from their medical charts. These patients were followed up prospectively for 1 year post discharge with all unplanned readmissions to general medical (including cardiology) wards during this time period recorded. Univariate analysis (chi-squared) was used to identify variables that had at least a minimal association with one or more unplanned readmissions 12 months post discharge (p < 0.25). These were entered into backward stepwise elimination logistic regression analysis (model entry set at p = 0.05). Examination of the significance of the log-likelihood ratio test for each variable determined its contribution to the model. Data from a total of 487 elderly patients (≥65 years of age) with non-elective admissions to general medicine wards were used to refine the readmissions model. The refined model was then validated using similar data retrospectively collected from medical charts regarding 732 elderly patients (≥65 years of age). Multivariate logistic regression analysis yielded a nine-variable model, which contained both predictive and protective variables for one or more readmissions 12 months post discharge from hospital. This model had a specificity of 79.3%, sensitivity of 60.0% and overall accuracy of 71.2% (cut-off point of p = 0.5). When the model was applied to the validation population, an overall percentage accuracy in classification of 65.2% was obtained. This refined and validated hospital readmissions predictive model could be used by healthcare professionals to help identify vulnerable patients upon admission to hospital, and to put in place a comprehensive discharge planning process.

Aims Helicobacter pylori (H. pylori) eradication rate varies according to the treatment regimen used and other factors, e.g. antimicrobial resistance and patient compliance. The aim of the present study was to evaluate the influence of patient counselling and follow-up on H. pylori eradication rates and to document the effectiveness of a 1 week eradication regimen consisting of lansoprazole (30 mg once daily), amoxicillin (1 g twice daily) and clarithromycin (500 mg twice daily). Methods Seventy-six dyspeptic patients, who at endoscopy were found to have gastritis, duodenitis or ulceration, and a positive H. pylori urease test, were recruited. Patients were randomly assigned to an intervention group (n = 38) or a control group (n = 38). Intervention patients received their medicines via the hospital pharmacy and were counselled (and followed up) by a hospital pharmacist. Control patients were given a standard advice sheet and referred to their GP who prescribed the same therapy. Results Intervention patients exhibited a statistically significant improvement in the H. pylori eradication rate (94.7% vs 73.7%; P = 0.02) and compliance (92.1% vs 23.7; P

Aim: The aim of this study was to introduce a protocol for the use of antimicrobials in surgical prophylaxcis for the described procedures in Antrim Area Hospital.Method: Historical data of antimicrobial use were obtained from retrospective analysis of patients' charts, for those patients identified as having one of teh following 'clean / contaminated' surgical procedures over the previous six months; cholecystectomy or abdominal hysterectomy. These data were analysed, and a protocol was introduced providing guidelines for the choice of antimicrobial agent, its administration time, route, dose, duration and frequency of treatment.Main outcome measure: The main outcome measure was the success of the uptake of the protocol following its implementation.Results: There was a total of 285 patients identified, 105 prior to and 180 post implementation. Overall 68% of patients received some form of prophylaxis in the first cycle, and 72% in the second.Conclusion: Although the introduction of the protocol led to slight improvements in compliance with standard prescribing procedures, with an increase in single-dose prophylaxis, and a reduction in prolonged prophylactic treatment, teh improvements did not reach expectations. This paper attempts to identify the possible barriers to protocol implementation.

Background Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile are major nosocomial pathogens whose control relies on effective antimicrobial stewardship and infection control practices. This study evaluates the impact of a chlorine dioxide-based disinfectant (275 ppm) on the incidence of hospital-acquired (HA) MRSA and HA- Clostridium difficile infection (CDI) in a district general hospital. Methods This study was carried out from November 2009 to September 2013. From November 2009 to October 2011 sodium dichloroisocyanurate was used for routine environmental disinfection. In November 2011, this was changed to a chlorine dioxide 275 ppm based disinfectant. This product was introduced into the hospital in a phased manner with intensive training on its use provided to all nursing, nursing auxiliary and hotel services staff. The effect of this change on the incidence of HA-MRSA and HA-CDI was assessed using segmented regression analysis of interrupted time series. In addition, the potential cost savings as a result of this intervention were assessed. Results The HA-MRSA trend from November 2009 to October 2011 significantly increased (p=0.006). Following the introduction of the chlorine dioxide-based disinfectant there was significant decrease in the HA-MRSA trend, with the monthly incidence being reduced by 0.003 cases/100 bed days (p=0.001), equating to an average of four cases per month after 12 months of use This resulted in an annual potential cost saving of £276 000. No significant effect on the incidence of HA-CDI was observed (coefficient −0.03; p=0.873). Conclusion This study highlights the importance of effective environmental inanimate surface decontamination in controlling the spread of MRSA and the potential cost savings that can be achieved through decreasing HA-MRSA rates.

This study aimed to determine the value of using a mix of clinical pharmacy data and routine hospital admission spell data in the development of predictive algorithms. Exploration of risk factors in hospitalized patients, together with the targeting strategies devised, will enable the prioritization of clinical pharmacy services to optimize patient outcomes.Predictive algorithms were developed using a number of detailed steps using a 75% sample of integrated medicines management (IMM) patients, and validated using the remaining 25%. IMM patients receive targeted clinical pharmacy input throughout their hospital stay. The algorithms were applied to the validation sample, and predicted risk probability was generated for each patient from the coefficients. Risk threshold for the algorithms were determined by identifying the cut-off points of risk scores at which the algorithm would have the highest discriminative performance. Clinical pharmacy staffing levels were obtained from the pharmacy department staffing database.Numbers of previous emergency admissions and admission medicines together with age-adjusted co-morbidity and diuretic receipt formed a 12-month post-discharge and/or readmission risk algorithm. Age-adjusted co-morbidity proved to be the best index to predict mortality. Increased numbers of clinical pharmacy staff at ward level was correlated with a reduction in risk-adjusted mortality index (RAMI).Algorithms created were valid in predicting risk of in-hospital and post-discharge mortality and risk of hospital readmission 3, 6 and 12 months post-discharge. The provision of ward-based clinical pharmacy services is a key component to reducing RAMI and enabling the full benefits of pharmacy input to patient care to be realized.