[Reorganization of clinical trial activity in a hospital pharmacy: Contribution of Lean management]. / Réorganisation de l'activité des essais cliniques dans une pharmacie à usage intérieur : contribution du Lean management.

OBJECTIVES: Hospital pharmacists are involved in clinical trials for the management of experimental drugs. In our hospital, the pharmacy is in charge of approximately 120 clinical trials and this activity is sub-divided between three sectors. The fragmentation of this activity generates difficulties in terms of heterogeneity of practices, redundancy of activities, and difficulties of communication with stakeholders outside the pharmacy due to the multiplicity of pharmaceutical interlocutors. The aims of this work were to improve and harmonize practices, and to reorganize and globalize the activities carried out in this sector. METHODS: A Lean management approach was employed. The process was mapped and then a double analysis was conducted. On the one hand, wastes and irritating were identified collaboratively, at project group meetings. On the other hand, a reorganization model was proposed. RESULTS: A diagnosis with 38 points to improve was drawn. The reorganization applied to human resources, by reducing the number of actors involved in a rational way, and secondly, tasks were revised and harmonized. CONCLUSIONS: The use of a lean methodology allowed us to perform successfully our reorganization. This approach led to continuous improvement in a collaborative manner in this sector.

[Ensuring safety of patients under antipsychotic drugs: Impact of medical and pharmaceutical collaboration at prison]. / Sécurisation de la prise en charge médicamenteuse des patients sous antipsychotiques : impact de la collaboration médico-pharmaceutique à la Maison d'Arrêt de Lyon-Corbas.

OBJECTIVE: Antipsychotics are the standard treatment for psychosis. However, when combined with other lifestyle factors they are partially responsible for an excessive mortality rate. A clinical and paraclinical monitoring of patients is therefore necessary. In 2011, this element led doctors and pharmacists to improve monitoring and formalize a follow-up adapted to inmate patients. The aim of this study was to assess the impact of medical-pharmaceutical collaboration on monitoring quality of patients treated by antipsychotics. METHODS: This is a retrospective study including all patients treated by antipsychotics for at least 6 months in 2011 and again in 2015. Data were collected from medical files. The indicator assessing the monitoring quality was the compliance percentage, of registred parameters for each patient on the basis of specific guidelines. RESULTS: In 2015 compared to 2011, the monitoring quality increased for 9 out of 10 parameters. This improvement was statisticaly significant for 7 of them : Body Mass Index, lipid test, complete blood count, transaminase, ionogram, glycemia, glomerular filtration rate. CONCLUSION: The actions of improvement collectivelly implemented in 2011 had a concrete impact on patients in the follow-up in 2015.

Benzodiazepine dose reduction in prisoner patients: 15 years' teamwork between psychiatrists and pharmacists.

WHAT IS KNOWN AND OBJECTIVE: Benzodiazepines are widely consumed in prisons, despite the iatrogenic risks associated with this therapeutic class. A multidisciplinary pharmacotherapy programme was therefore initiated by pharmacists in 2001. The aim of this study was to demonstrate the efficacy of teamwork between psychiatrists and pharmacists in benzodiazepine dose adjustment, with 15 years of hindsight. METHOD: In this retrospective study, daily prescribed benzodiazepine doses were compared between a reference group of patients in prisons in Lyon, France, in 2000, and four groups after psychiatrist-pharmacist teamwork in 2004, 2008, 2012 and 2016. RESULTS AND DISCUSSION: A number of 1249 patients were included. Prescribed doses of benzodiazepine decreased in the intervention groups, to a mean of 29-35 mg diazepam equivalent per day, compared to the control group (42 mg/day) (P < .001). The first 4-year period (2000-2004) demonstrated that monthly meetings and systematic pharmaceutical medication review had an impact on prescribed benzodiazepines, limiting consumed doses. The others (2004-2008, 2008-2012 and 2012-2016) confirmed that physicians' adherence to prescription guidelines and the efficacy of pharmacotherapy programme was maintained, particularly in those inmates taking high doses. WHAT IS NEW AND CONCLUSION: A continuous quality programme conducted by psychiatrists and pharmacists showed positive impact in reducing doses of benzodiazepine prescribed to prisoner patients and contributing to reduce risk of benzodiazepine-related problems.

[Drug management of prisoners: Role of the pharmaceutical staff to ensure patient safety]. / Prise en charge médicamenteuse en milieu carcéral : contribution de l'équipe pharmaceutique à la sécurité des patients.

OBJECTIVES: In the prisons of Lyon, drug management of inmates implies cooperation between general practitioners, psychiatrists and pharmacists. All the medical prescriptions are reviewed by the pharmacists of the medical unit. The aim of this work was to synthesize the pharmaceutical interventions performed and show the implication of the pharmaceutical staff in detecting and handling prescribing errors. METHODS: Pharmaceutical interventions performed between the 1st of June 2012 and the 31st December 2014 and entered in the Act-IP(®) database (SFPC) were retrospectively analyzed. RESULTS: Among the 18,205 prescriptions reviewed, 4064 (22.3%) had a prescription error. The main problems encountered were by decreasing order of frequency: missing monitoring (15% of the interventions), lack of compliance (13%), over dosage (10%), lack of conformity with recommendations or consensus (8%). Interventions were accepted in 78% cases. Most prescribing errors implied medications of the central nervous system. Among the interventions, 8% were initiated by pharmacy technicians, mainly lack of compliance. CONCLUSIONS: The pharmaceutical interventions reported reflected actions of securisation initiated by the pharmacists in cooperation with physicians: monitoring of patients taking antipsychotic medications or benzodiazepines maximal dosages. Besides, in this population with a high prevalence of psychiatric comorbidities and important suicide rate, detection of patients with default of compliance is one of the keys for drug optimization among these patients as it is an explanation for therapeutic failure.

Population modeling and simulation study of the pharmacokinetics and antituberculosis pharmacodynamics of isoniazid in lungs.

Among first-line antituberculosis drugs, isoniazid (INH) displays the greatest early bactericidal activity (EBA) and is key to reducing contagiousness in treated patients. The pulmonary pharmacokinetics and pharmacodynamics of INH have not been fully characterized with modeling and simulation approaches. INH concentrations measured in plasma, epithelial lining fluid, and alveolar cells for 89 patients, including fast acetylators (FAs) and slow acetylators (SAs), were modeled by use of population pharmacokinetic modeling. Then the model was used to simulate the EBA of INH in lungs and to investigate the influences of INH dose, acetylator status, and M. tuberculosis MIC on this effect. A three-compartment model adequately described INH concentrations in plasma and lungs. With an MIC of 0.0625 mg/liter, simulations showed that the mean bactericidal effect of a standard 300-mg daily dose of INH was only 11% lower for FA subjects than for SA subjects and that dose increases had little influence on the effects in either FA or SA subjects. With an MIC value of 1 mg/liter, the mean bactericidal effect associated with a 300-mg daily dose of INH in SA subjects was 41% greater than that in FA subjects. With the same MIC, increasing the daily INH dose from 300 mg to 450 mg resulted in a 22% increase in FA subjects. These results suggest that patients infected with M. tuberculosis with low-level resistance, especially FA patients, may benefit from higher INH doses, while dose adjustment for acetylator status has no significant impact on the EBA in patients with low-MIC strains.

[Analysis of the question-answer activity of a hospital pharmacy. Example of the handling of drug interactions]. / Analyse de l'activité question-réponse d'une pharmacie à usage intérieur. Exemple de la gestion des interactions médicamenteuses.

INTRODUCTION: The medical care of patients generates questions among healthcare professionals. Some will necessitate an advanced research. The hospital pharmacist is at the interface between prescribers, caregivers and the medicines and is requested to answer these requests. Studies conducted in other countries showed that this question-answer activity represents a significant amount of time in daily work. In France, this topic was poorly explored. The objective of our work was to study the volume and the type of questions, the clinical situations, the time required, the medicines implicated and the sources of information used. MATERIALS AND METHODS: A prospective study was conducted in the pharmacy of a university hospital. All the requests answered by the pharmaceutical team, which needed a specific research, analysis and writing of an answer were collected. RESULTS: A hundred and one questions were analyzed, originating from doctors or medicals interns. Almost half concerned drug interactions, and among them, almost a fourth were not mentioned in the Summary of Product Characteristics of the medicines involved. A pharmaceutical advice was provided in 91.5% of the cases. Time dedicated to the research varied between less than 30 minutes and more than 8 hours. DISCUSSION AND CONCLUSION: This study illustrates the question-answer activity of a hospital pharmacy, which is currently not taken into account as an indicator of pharmaceutical activity. A large part concerns analysis and management of drug interactions and requires a significant amount of pharmaceutical time.