Austria 1652011

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Role of Pharmacists in Pediatric Oncology

Sherif Kamal

DPS Director

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Clinical Pharmacy - Egypt

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Clinical Pharmacy Story - Egypt

• Implementation

• Measurement

• Sharing

NCI/Naser/Pyramids/Zagazig/

Tanta

Menya Clinical

Pharmacy Program Assuit

Clinical course

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Challenges

Value of the Clinical Pharmacist

• 1 $ for Clinical Pharmacy = 14 $ ROI

• 1 $ for Patient Education = 4 $ ROI

• IV saving

• TDM saving

• Hospital Mortality

Our Challenge

In Egypt, In Egypt,

8,000 children8,000 children

are diagnosed are diagnosed

with cancerwith cancer

every yearevery year

Change

Change

NCI CCHE

• Change – Design,– Functionality– space

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Vision

• The vision of the CCHDPS is to enhance patients' quality of life And to obtain positive patient outcomes.

Mission

• The DPS will provide a state-of-art comprehensive pharmaceutical care that is patient centered; focusing on evidence based innovative techniques and scientific research, to reduce morbidity and mortality of children with cancer.

57357 Children’s Cancer Hospital

Cairo, Egypt

6-10 June, 2010

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Pharmacy Statistics• Items charged = 70,921• MAE = 62,137• Total no. of orders = 30,100• Doses = 91,142• Patient transaction = 4216• Days of medication service = 5229• IV orders = 15,438• IV dose = 31491• Lab= 552• Working hours = >13000• Total no. of trainees =210

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Org Structure

CCHE DPS Components1. I.V admixture2. Patient Services3. Ambulatory Care (OPD/DC/MSC) 4. TPN5. Dispensing 6. Drug Information 7. Therapeutic Drug Monitoring 8. Nuclear Pharmacy (New Service)9. Critical Care Pharmacy (New Service)10. Pain Service (New Service) 11. Controlled Substances 12. Neuro-Care Pharmacy (New Service) 13. Pharmacoeconomic services 14. Drug Procurement Office 15. Pharmacoinformatics 16. Quality Management 17. Safe handling of Hazards Material and Waste management 18. Clinical Trials 19. Newsletter and websites

Drug Procurement Office Tender Document

IV admixture

• IV prep

• IV Mix

• TPN

• IV check

Dispensing

• Out Patient

• In Patient

• Day Care

• Patient Education

Assessing Dispensing Errors

Patient Education

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WHENEVER POSSIBLE USE PATIENT EDUCATION MATERIAL

Imatinib

Labels

PATIENT EDUCATION MATERIAL

Brochures

Wall Papers

PATIENT EDUCATION MATERIAL

Wall Papers in the Waiting Area

Patient BookletsPATIENT EDUCATION MATERIAL

Patient Flyers

PATIENT EDUCATION MATERIAL

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Assessing Quality of Patient Education

Assessment of patient adherence

• Objective:– This study is an attempt to examine patient

compliance.

• Specific objective: – to investigate the extent to which a patient's

behavior taking medications.– To investigate adherence to physician's

orders.

Assessment of patient adherence

Round 10:1

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Case

• Name : AS• Presented on 17/12/2007- ICU 7 pm • TLC 390 000• LDH 15438

Management on 17/12Hydration Urine PH = 6S.cr 4.1Decision to give Rasburicase 0.2 mg /kg G-6PD tested

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Case L4• Name : NI• Presented on 7/2/2008- ICU 16:00

pm • TLC 23 500 • LDH 2283 IU/l

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Effectiveness of Ondansetron

First ICU Clinical Pharmacy

• 37% higher mortality and 14.8% longer ICU stays

• 184 extra deaths, 59,429 extra hospital days, $215,397,354 extra total Medicare charges, and $26,363,674 extra drug charges,"

MacLaren R and Bond CA. Effects of pharmacist participation in intensive care units on clinical and economic outcomes of critically ill patients with thromboembolic or infarction-related events. Pharmacotherapy. 2009; 29:761-8.

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Stewardship program

Discussion and recommendations

Discussion and recommendations

Discussion and recommendations

Restricted drug List

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Dexamethasone Use inBT

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My Experience with Brain T in a baby Girl

Role of Pharmacists in Protocol Management

PK lab

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RELATION BETWEEN VALPROIC ACID ADMINSTRATION AND THE INCIDENCE OF THROMBOCYTOPENIA

• Introduction: Valproic acid is used in our setting as antiepileptic drug either alone or in combination with other antiepileptic drugs.Thromhocytopenia in association with valproic acid therapy has been reported in patients of various ages with incidences ranging from 1 to 32%. Regarding the pathophysiology of the Thromhocytopenia associated with valproic acid therapy, there is evidence to suggest that valproic acid can evoke an immune response with the production of antibodies directed against platelets. Sandler described circulating and bound platelet antibodies of the IgM type . Especially in pediatric oncology setting where thromhocytopenia is common it is very essential to study this association.

• Materials & Methods: To evaluate this association in a pediatric population, we retrospectively studied 55 children treated with valproic acid(VPA) at our institution in April 2010.The patient medical files were reviewed The Incidence of thrombocytopenia were recorded based onthat Thrombocytopenia was defined as a platelet count ~200 x 103/mm3.The valproic acid levels of these patients were also recorderded in this period of time .

• Results: We retrospectively studied  children treated with valproic acid(VPA) at our in April 2010. The Incidence of thrombocytopenia in Valproic acid population was 17% which is within the range of the benchmark .Only 50 % of the cases having thrombocytopenia showed normal therapeutic level values .25 % of the patients having thrombocytopenia showed higher level of valproic acid and 25% showed subtherapeutic levels and required increase in dose .

• Discussion, Conclusion: The Incidence of thrombocytopenia in Valproic acid population is less than 17% which is within the range of the benchmark .The correlation between the incidence of thrombocytopenia and the drug level need to be further studied and this is next on our agenda.But we recommend that  platelet counts should be closely monitored in patients recieving valproic acid especially in patients were we are going to increase the dose due to subtherapeutic levels.

Pharmacy Automation

57357 - Vital Signs

Metric NameTotalDaily Average

Appointments 15,222491

Registrations 11,970386

Charts Open209,8796,770

Orders239,0887,713

Inbound Interfaces 17,323642

Outbound Interface45,7221,475

Work Load

*August 2010 Monthly Cumulative Figures

24 Hour Snap Shot in 57357 Metric Value

Logins 3,421

Nurse Assessments / Forms Completed 2,001

PAL Opened 828

All Orders Written 10,177

Total Medication Orders 4,033

Total Medications Administered 4,379

Lab Orders 4,868

Total Charts Opened 7,460

Physicians – PowerNotes Documented 263

Physicians – PowerNotes Signed 301

Alerts Fired 411

*Data Captured Thursday September 16th 2010

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4169

Newsletter

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Vincristine

• Lookalike /Soundalike

• TALLman :vinCRIstine====vinBLAstine

• Peripheral neuropathy

• Bilrubin

• Cell cycle specific

• Extravasation

Role Of Pharmacists as patient Safety Officers

LASA

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Triple ITH

• 3 drugs together?

• Package (Filter ,Alcohol swabs,dressing)

• When to give /HDMTX?

• Error

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What To Do?

• Color Coding

• VCR as IV bag

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HFMEA

• Cheng C. H. et al. (2010). Applying HFMEA to Prevent Chemotherapy Errors. Journal of Medical Systems. Available at http://www.springerlink.com/content/j47u588376g58p87/fulltext.pdf

• Failure mode and effect analysis (FMEA) is a systematic and prospective risk evaluation method initially adopted in the industrial field.

• It has been widely used by engineers to improve the reliability, quality, and safety of their products and to reduce potential risks. The most important function of FMEA is to identify potential failure modes for each subsystem or component.

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IHI

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Mucositis Mucositis

II - Accurate number of patients having OM - Accurate number of patients having OM

Which include: category II & IV (NO/YES & YES/YES)Which include: category II & IV (NO/YES & YES/YES)

a) % of mucositis occurrence : 51%

b) Relation to gender: male (60%) & females (40%)

c) Relation to age :

• From 0.6 to 6 years : 50%

• From 7 to 12 years : 24%

• From 13 to 19 years : 26%

Analysis of dataAnalysis of data

e) Relation to prophylaxis :e) Relation to prophylaxis : • 48% of these patients use prophylaxis.

• 52% of these patients don’t use it.

f) Type of prophylaxis :f) Type of prophylaxis :

TypeTypePercentage %Percentage %Hexitol41%

Nystatin76%

Miconazole63%

mouthcare43%

Analysis of dataAnalysis of data

d) Cancer type :d) Cancer type :

• ALL : 37%

• AML : 27%

• NHL : 18%

• OS : 1%

• RMS : 11%

• Others : 3% (ES,RM & WT)

Analysis of dataAnalysis of data

g) Grade of mucositis:g) Grade of mucositis:

gradegradePercentage %Percentage %

G1G110%

G2G224%

G3G310%

G4G410%

HLHL16%

WPWP9%

PIPI9%

PI & CanPI & Can1%

Ulcers on mouthUlcers on mouth8%

Analysis of dataAnalysis of data h) Dose of chemotherapy:h) Dose of chemotherapy:

• The doses of chemotherapy are just before occurrence of OM :

dosesdosesPercentage %Percentage %MTX14%

6-MP9%

VCR14%

CYTRA16%

DOXO18%

DEXA2%

ETOPO7%

CYCLO7%

HC3%

PREDN.06%

ASPARA4%

IFOSF.1%

BETA.06%

CARBO.06%

DAUNO.06%

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Asparaginase prep

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Cyclophosphamide

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Tannic Acid as effective Hemostatic agent in pediatric adenocarinoma :A case Study

• Introduction:  Standard treatment of profuse bleeding was done using patches of oxidized regenerated cellulose .There are no reports on managing failure of oxidized regenerated cellulose patches .Using tannic acid solution was recommended by the Chief Surgeon in the hospital ,the pharmacy looked up the extemporaneous formulation of tannic acid and followed up the patient .

• Materials & Methods:   This was a real time case study  in the children cancer hospital Egypt Tannic acid was prepared as a 40% solution in water and was applied to the surgical site three times daily as compresses for 3 month as the patient was on palliative treatment. The number of transfusion before and after using the Tannic acid preparation were studied. The efficacy of the haemostatic activity was measured by the number of blood transfusion and stopping the bleeding.

• Results:  

• After the last operation the patient suffered from severe bleeding from the surgical site.

• Patches of oxidized regenerated cellulose was given to control bleeding with no success, where 3 blood transfusions were needed. After using the Tannic acid 40 % the need for transfusion decreased to one transfusion in the first week followed by three weeks without transfusion.

• Discussion, Conclusion: As mentioned by the mother the severe bleeding prevented the efficacy of the Patches of oxidized regenerated cellulose by detaching the patch from the site of bleeding  also she noted that the size of surgical site was preventing fitting the patch. The tannic acid 40% preparation in water and was applied to the surgical site three times daily as compresses for 3 month was ver effective in stoping bleeding and improving the quality of life of our patient . The Role of the pharamcists was very clear in following up the case detecting the need for another intervention , searching for evidence for the new intervention ,implementing the intervention then following up and reporting the case. 

Monitoring of Toxicity

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Amphotericin B vs. Liposomal Ampho B

Tele-Pharmacy

• Using hybrid solutions for maximizing the return on investment from telemedicine in pharmacy education

• 5^th Annual Pediatric Tele-health Colloquium at the 2010 American Telemedicine Association

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Training

• 15 Orientation Trainee per week

• Sudan

• Salam Hospital

• MOH Oncology Centers

• Clinical Pharmacy Students (100 hr)

• SCOPS

• Helwan

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Training Program

• This program will discuss aspects of Clinical Pharmacy and pharmaceutical care with particular emphasis on the application in the hospital.

• The duration of the program will be 2 Weeks (100 hrs) from Sunday – Thursday, 8 hours each day, where there will be lectures (1 hr min x5 lectures= 5 hrs), on the job training (OJT) (8 hr X 10 days= 80hrs) and 15 hrs final project .

• During the OJT the trainee will be rotated to work in the different areas of the Department of pharmaceutical services in hospital 57357.

• The participant will undergo pre and post-lecture Exams and will be evaluated at the different work sites, each trainee will be assigned to make a project with a final exam written.

• The project assignment will be the development of Pharmaceutical Care Plans for the patients and Study proposal.

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Cairo 100 hr Perceptorshipand Academic Platform

Helwan University

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MISK

DPS 2020

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