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Za uvajanje kliničnega farmacevta v zdravstveni tim je nujno potrebna podpora najvišjega vodstva bolnišnice, ki je zadolženo za izvajanje varnostne politike pri zdravljenju in za finančno poslovanje bolnišnice. Sprejetost kliničnega farmacevta s strani drugih zdravstvenih delavcev je tem boljša, čim bolj njegove aktivnosti ustrezajo pričakovanjem in potrebam uporabnikom njegovih storitev, to so predvsem zdravniki in medicinske sestre. Ugotavljanje potreb in pričakovanj uporabnikov je zato prva in ključna aktivnost pri načrtovanju katerekoli nove storitve, kar klinična farmacija v slovenskem prostoru vsekakor je. V Univerzitetnem kliničnem centru Ljubljana (UKCL) se dejavnost klinične farmacije do leta 2010 ni izvajala. Čeprav je vodstvo ustanove uvedbo te dejavnosti podpiralo, pa so neformalno izražena mnenja posameznih predstojnikov kazala na to, da je mnenje glede uvedbe klinične farmacije do določene mere deljeno tudi med predstojniki kliničnih oddelkov. Pred začetkom uvajanja klinične farmacije je bilo zato ugotavljanje potreb in pričakovanj bodočih uporabnikov, predvsem predstojnikov kliničnih oddelkov ter njihovih glavnih medicinskih sester, ključnega pomena, saj je za kakršnokoli dejavnost na posameznem oddelku dovoljenje oz. podpora predstojnika nujni pogoj. Sodobna družba, ki jo lahko označimo tudi kot »podatkovno« družbo, se srečuje z izzivom obvladovanja podatkov in predvsem z iskanjem metod za njihovo analizo, saj podatki sami po sebi še ne prinašajo nobene dodane vrednosti. Potreba po razumevanju velikega števila podatkov je narekovala razvoj številnih metod za analizo podatkov, ki izhajajo iz umetne inteligence in statistike. Odkrivanje znanja iz podatkov je definirano kot kompleksno pridobivanje implicitnih, neznanih in potencialno uporabnih informacij iz podatkov. Rudarjenje podatkov (data mining) je postopek, s katerim iz velikih podatkovnih zbirk poiščemo pomembne skrite napovedne informacije. Osnova za podatkovno rudarjenje so zbirke podatkov, statistične metode in algoritmi strojnega učenja ter umetne inteligence. Podatkovno rudarjenje omogoča avtomatizirano napovedovanje bodočih trendov in obnašanja ter avtomatizirano odkrivanje prej neznanih vzorcev. V množici metod podatkovnega rudarjenja so bile razvite tudi številne metode, namenjene analizi majhnih vzorcev. Tudi medicina in farmacija sodita med znanstvena področja, kjer v določenih primerih ni mogoče zagotoviti velikega vzorca, na primer pri raziskovanju redkih bolezni. Podobno je področje tržnih raziskav in raziskav zadovoljstva uporabnikov (marketing research, customer satisfaction). V ta namen je bilo treba razviti prilagojene metode, ki so primerne za analizo majhnih vzorcev, ki pa obenem zagotavljajo ustrezno napovedno moč raziskave. Za analizo majhnih vzorcev z velikim številom spremenljivk se običajno uporabljajo tehnike izbora pomembnih spremenljivk za dani klasifikacijski problem. Vsako od spremenljivk opredelimo glede na njen pomen za določen razred. Na ta način lahko v praksi spremljamo le tiste spremenljivke, ki imajo največji pomen za dani problem, saj vsebujejo vso potrebno informacijo za opredelitev razreda. Navedene zakonitosti in znanja s področja umetne inteligence smo uporabili za analizo podatkov anketnega vprašalnika o vlogi kliničnega farmacevta v UKCL. Na osnovi obsežnega pregleda literature smo izdelali nabor aktivnosti kliničnih farmacevtov, ki je služil za oblikovanje vprašalnika. Izhodiščne potrebe in pričakovanja uporabnikov storitev kliničnega farmacevta v UKCL smo preverili z vprašalnikom za ocenjevanje pomembnosti posamezne aktivnosti po Likertovi ocenjevalni lestvici. Validacijo vprašalnika smo izvedli s pomočjo ekspertnega pregleda treh ekspertov, in sicer enega od predstojnikov, sodelujočih v raziskavi, farmacevta, zaposlenega izven bolnišnične lekarniške dejavnosti, in neodvisnega strokovnjaka s področja upravljanja s kadri. Vprašanja v vprašalniku so razdeljena na tri vsebinske dele: vloga kliničnega farmacevta v sistemu bolnišnice (17 vprašanj), vloga kliničnega farmacevta ob pacientu (19 vprašanj) in pomen kompetenc za uspešno delo kliničnega farmacevta (16 vprašanj). V prvih dveh vsebinskih delih je anketiranec izrazil svoje strinjanje ali nestrinjanje s trditvijo z ocenami od 1 (sploh se ne strinjam) do 5 (zelo se strinjam), pri tretji pa je z ocenami od 1 (ni pomembna) do 5 (zelo je pomembna) opredelil, koliko je pomembna posamezna splošna oziroma specifična kompetenca za uspešno delo kliničnega farmacevta. Vprašalnik smo poslali v ocenjevanje vsem predstojnikom, glavnim medicinskim sestram in farmacevtom v bolnišnici. Prejete odgovore smo zbrali v podatkovni tabeli, ki je služila kot osnova za vse nadaljnje analize. V prvem poglavju prikažemo rezultate analize z neparametričnimi ANOVA testi. Ugotovili smo, da se stališča posamezne poklicne skupine glede dejavnosti klinične farmacije razlikujejo tako pri posameznih aktivnostih kot tudi pri sklopih aktivnosti. Največje razlike opazimo med farmacevti in medicinskimi sestrami, pomembne razlike pa so tudi v stališčih zdravnikov in farmacevtov. Manj se razlikujejo stališča zdravnikov in medicinskih sester. Srednja vrednost strinjanja zdravnikov z aktivnostmi prvega in drugega sklopa je bila 4.28 oz. 3.73, medtem ko so bile te vrednosti pri medicinskih sestrah ovrednotene nižje, in sicer 3.87 oz. 3.38. Srednje vrednosti ocen farmacevtov za zadevna dva sklopa so bile bistveno višje, in sicer 4.57 in 4.23. Navedena vsebina je bila objavljena v reviji Acta Pharmaceutica 64 (2014) 447-461. V nadaljevanju smo v UKCL vzpostavili sodelovanje kliničnih farmacevtov na izbranih oddelkih v bolnišnici. Rezultate anket smo dopolnili z ekspertno oceno vodje lekarne glede uspešnosti sodelovanja. Tako dopolnjeno tabelo smo uporabili za analizo s pomočjo algoritmov strojnega učenja. V drugem poglavju so predstavljeni rezultati analize podatkov s pomočjo algoritma OrdEval (programsko okolje R, paket CORElearn), ki nam omogoča tudi ugotavljanje vrste vpliva posamezne aktivnosti na celotno zadovoljstvo. Rezultate smo uporabili za kategorizacijo aktivnosti kliničnih farmacevtov v skladu s Kanovim modelom. Šest aktivnosti smo razvrstili v skupino pričakovanih elementov (performance), deset v skupino privlačnih (excitement) in eno v skupino potrebnih (basic). Za ocenjevanje pomembnosti spremenljivk lahko uporabimo tudi algoritma ReliefF in MDL (programsko okolje R, paket CORElearn). Z njuno uporabo smo ocenili, katere dejavnosti klinične farmacije (atributi) so za zdravnike in medicinske sestre najbolj pomembne in katere najmanj, ter v kolikšni meri se pomembnost posamezne dejavnosti ujema z ekspertno oceno vodje lekarne in z rezultati predhodno uporabljenega algoritma. Rezultati so prikazani v tretjem poglavju in kažejo, da je uporaba različnih algoritmov smiselna, saj je v primeru ujemanja rezultatov zanesljivost ugotovitev večja. Tako smo ugotovili dobro ujemanje obeh algoritmov z oceno vodje lekarne pri osmih aktivnostih kliničnih farmacevtov. Za ocenjevanje zadovoljstva s klinično farmacijo smo nato izvedli še pol-strukturirane intervjuje s predstojniki petih oddelkov, na katerih se izvaja klinična farmacija, in s pomočjo odgovorov določili uspešnost kliničnih farmacevtov. Odgovore smo analizirali s pomočjo orodja za analizo besedila QDA Miner text management and qualitative coding software (QDA Miner 4, Provalis research). Ugotovili smo, da sta med dejavnostmi klinične farmacije dve, ki ju lahko uvrstimo v skupino obratnih (reversal) elementov, česar z uporabo algoritmov strojnega učenja nismo zaznali. For a successful introduction of clinical pharmacy services on the wards of a hospital, the support of hospital management is crucial. The acceptance of a clinical pharmacists by other members of the health care team depends mainly on their individual attitude, perception, and personal experience. It is necessary to investigate the needs and expectations of the users before the introduction of any new service, including clinical pharmacy. Clinical pharmacy (CP) service was not used in University medical Centre Ljubljana before 2010. Although the management strongly supported the introduction of clinical pharmacists into health care teams, some of the head physicians doubted it. Before the introduction of clinical pharmacy service in the hospital it was necessary to assess the attitudes of head physicians and head nurses about it, as well as the attitudes of pharmacists as potential providers of the new service. Contemporary society is characterized by plethora of hardly manageable data. The need to store and analyse a huge amount of data and discover useful information hidden in it lead to the development of new methods based on artificial intelligence approaches, statistical methods and machine learning algorithms. Data mining is a process to explore big data warehouses and data bases to discover hidden information and knowledge. Data mining techniques allow automatic prediction of future trends and behaviours, and automatic discovery of hidden patterns in data. In plethora of new methods, we can find some, which are capable to analyse small samples. Medical and pharmaceutical sciences often lack big samples, which is true also in marketing and user satisfaction studies. To analyse small samplesclassification approaches often extract important variables for a given problem. Each variable is evaluated according to the class in question. In practice this means that we can consider only the variables with the strongest impact on the outcome of a given classification problem. Based on these considerations we conducted a survey about the role of clinical pharmacist in University medical Centre Ljubljana. A comprehensive literature search was performed to prepare a list of all possible clinical pharmacy activities. The list was further used to construct a survey questionnaire with Likert measurement scale to conduct a descriptive observational attitude study of physicians’ and nurses’ opinion about the importance of each of the listed activities and competencies of clinical pharmacists. The questionnaire was validated by three experts, a non-hospital pharmacist, hospital head physician, and a human resource manager. The questionnaire is composed of three types of questions. In the first part of the questionnaire (17 questions), clinical pharmacy activities pertaining to the hospital system are stated, while the second part of the questionnaire (19 questions) contains activities directly connected with individual patient’s care. The third part (16 questions) of the questionnaire deal with clinical pharmacist’s competencies. The participants had to choose the level of agreement on the Likert scale from 1 (I totally disagree) to 5 (I totally agree) with each of the listed affirmative statements in the part one and two of the questionnaire, while indicating the importance (form least important – 1 to very important – 5) of a particular competence in the third part. The questionnaire was sent to 43 physicians – medical directors or heads of departments – and to their head nurses. The survey results were collected in a spreadsheet, which served as a basement for all following analyses. In the first chapter we discuss the results obtained with nonparametric ANOVA tests. We observed considerable differences between pharmacists, physicians and nurses in total mean score of agreement to each statement and to each group of statements. The largest differences exist between the mean scores of pharmacists and nurses. The differences between physicians and pharmacists are also important. The differences between physicians and nurses are smaller. Total mean score of physicians’ agreement with the first and second group of CP activities is 4.28 and 3.73, respectively, while these scores are lower for nurses (3.87 and 3.38 for the first and second group, respectively). Pharmacists’ total mean scores are highest, 4.57 and 4.23 for the first and second group, respectively. Afterwards this preliminary phase we established clinical pharmacy service on designated wards. The satisfaction with the new service was assessed by the head of the pharmacy and the values were entered into the database. This appended database was used to perform analyses with data mining algorithms. In the second Chapter we present the results obtained with OrdEval algorithm, which can determine the importance of each CP activity and their type according to the users’ expectations. The results were used to categorize the activities/competences according to Kano model. Using analysis of individual feature values, we identified six performances, 10 excitements, and one basic clinical pharmacists’ activity. Other feature evaluation algorithms, like ReliefF and MDL, can also be used for the assessment of the importance of the variables. Survey data were analyzed using these two algorithms to identify the most important clinical pharmacists’ activities/competences. The results were compared with the expert estimation of the head of the pharmacy and to the values calculated using OrdEval algorithm. The results are analyzed in the third Chapter. We conclude that using different data mining algorithms is justified. In the case of congruence of the results their reliability is improved. The results on importance of CP activities for both algorithms agreed with the expert estimation for eight CP activities/competences. Finally, in the fourth Chapter we present the pilot case study report on the text analysis of the text of five semi-structured interviews with head physicians about their satisfaction with clinical pharmacist after establishing the collaboration. The text was analysed with QDA Miner text management and qualitative coding software (QDA Miner 4, Provalis research). We identified two reversal CP activities according to Kano model which were not discovered in our previous analyses.

Background: Volunteers make a huge contribution to the health and wellbeing of the population and can improve satisfaction with care especially in the hospice setting. However, palliative and end-of-life-care volunteer services in the hospital setting are relatively uncommon. The iLIVE Volunteer Study, one of eight work-packages within the iLIVE Project, was tasked with developing a European Core Curriculum for End-of-Life-Care Volunteers in hospital. Aim: Establish an international consensus on the content of a European Core Curriculum for hospital end-of-life-care volunteer services which support patients in the last weeks of life. Design: Delphi Process comprising the following three stages: 1. Scoping review of literature into palliative care volunteers. 2. Two rounds of Delphi Questionnaire. 3. Nominal Group Meeting. Setting/participants: Sixty-six participants completed the Round 1 Delphi questionnaire; 75% (50/66) took part in Round 2. Seventeen participants attended the Nominal Group Meeting representing an international and multi-professional group including, clinicians, researchers and volunteer coordinators from the participating countries. Results: The scoping review identified 88 items for the Delphi questionnaire. Items encompassed organisational issues for implementation and topics for volunteer training. Three items were combined and one item added in Round 2. Following the Nominal Group Meeting 53/87 items reached consensus. Conclusion: Key items for volunteer training were agreed alongside items for implementation to embed the end-of-life-care volunteer service within the hospital. Recommendations for further research included in-depth assessment of the implementation and experiences of end-of-life-care volunteer services. The developed European Core Curriculum can be adapted to fit local cultural and organisational contexts.

Za kontrolo mikrobiološke kakovosti čistih prostorov v Lekarni Univerzitetnega kliničnega centra v Ljubljani (UKCL) smo uporabili relativno novo bioluminescenčno metodo merjenja celokupnega adenozin trifosfata (ATP), ki postaja vedno pogosteje uporabljena za oceno ustreznosti mikrobiološke čistosti površin, pa tudi v bolnišničnem okolju na intenzivnih enotah. Ker se v farmacevtski proizvodnji zaradi nedefiniranosti kriterijev ustreznosti in korelacije z obstoječimi metodami kontrole mikrobiološke ustreznosti še ne uporablja, predstavlja naše delo novost in pomemben prispevek na tem področju. Še več, testiranje smo izvajali v čistih prostorih in sterilni proizvodnji v klinični lekarni UKCL, kjer imajo ažurni podatki o ustreznosti mikrobioloških parametrov delovnega okolja še toliko večji pomen. Predvidevali smo, da je bioluminescenčna metoda kljub nizki mikrobni obremenitvi nadzorovanih prostorov zaradi svojega delovnega principa še dovolj občutljiva za rutinsko uporabo ter zaradi enostavnosti uporabna kot hitro in učinkovito orodje kontrole mikrobiološke kakovosti in kot orodje za zaznavanje sprememb ter spremljanje trendov. Na podlagi šestletnega spremljanja mikrobioloških pogojev sterilne proizvodnje v bolnišnični lekarni UKCL smo pripravili katalog mikrobiote, ki smo ga uporabili predvsem kot osnovo za proučevanje primernosti bioluminescenčne metode za kontrolo ustreznosti spremljanega delovnega okolja. Med izolati v posameznih čistih prostorih nismo zaznali bistvenih razlik – v vseh je bil pri več kot 70 % vseh izoliranih mikrorganizmih njihov izvor človek. Med izolati je bilo 76,7 % grampozitivnih bakterij, 8,7 % gramnegativnih bakterij ter 8,2 % gliv in plesni. Najpogosteje izolirane so bile bakterije rodu Staphylococcus spp., Micrococcus luteus, Acinetobacter in sporogene vrste Bacillus spp. Prvo in drugo hipotezo, ki pravi, da je bioluminescenčna metoda merjenja celokupnega ATP-ja primerna za oceno čistosti proizvodnega okolja ter tudi primerna za validacijo in kontrolo čiščenja, smo potrjevali s primerjavo s klasičnimi mikrobiološkimi metodami. Tretjo hipotezo, ki pravi, da je metoda dovolj občutljiva za uporabo v čistih prostorih, smo potrdili, ker so bile vse izmerjene količine prisotnega ATP-ja v vzorcih, ki so bili odvzeti v čistih prostorih, v merilnem območju opreme. Za potrjevanje četrte hipoteze, ki pravi, da za določeno okolje obstaja korelacija med izmerjeno količino RLU (Relative Light Unit) in CFU (Colony Forming Unit), smo program bioluminescenčnega testiranja izvajali paralelno s klasično mikrobiološko kontrolo. Za vrednotenje rezultatov in postavitev akcijskih mej smo prostore najprej razdelili v več smiselnih kategorij ter določili akcijske meje, nato pa iskali korelacijo obeh metod po posameznih kategorijah. Prvotno smo iskali korelacijo med CFU in RLU, vendar je nismo uspeli potrditi. V nadaljevanju smo zato metodi primerjali glede uspešnosti napovedi neustreznega rezultata. V dveh kategorijah prostorov sta bili metodi primerljivi, v dveh pa je bila metoda ATP superiorna. Zgornji rezultat je pravzaprav logičen, ker so v rezultatih bioluminescenčne metode zajete vrednosti ATP-ja, prisotnega v živih celicah, ki je v direktni korelaciji s CFU-jem, in sproščenega ATP-ja iz mrtvih mikroorganizmov ali/in zaostankov uporabljenih organskih materialov. Slednji je dejanski pokazatelj onesnaženja kot potencialnega gojišča za mikroorganizme ali potencialnega vira pirogenov, kar je za sterilno proizvodnjo prav tako pomembno kot sam intracelularni oz. mikrobni ATP. A new bioluminescence method for the measurement of total adenosine triphosphate (ATP) was used to control the quality of clean rooms for the preparation of individual parenteral therapies, which is becoming increasingly used method for assessing the suitability of surfaces, including the hospital environment on intensive care units. Due to the fact that in the pharmaceutical production due to the undefined criteria of relevance and correlation with the existing methods of microbiological compliance control, our work is a novelty and a great contribution in this direction. Moreover, testing was carried out in clean rooms and in sterile production, where the up-to-date data on the appropriateness of the microbiological parameters of the working environment have an even greater significance. It was assumed that the bioluminescence method, despite the low microbial load of the controlled premices due to its working principle, is sufficiently sensitive to routine use and, due to simplicity, is useful as a quick and effective quality control tool and a tool for detecting changes and monitoring trends. Based on a six-year monitoring program of the microbiological conditions of sterile production at the UKCL Pharmacy, we prepared a microbiota catalog, which was used primarily as a basis for studying the suitability of the bioluminescence method for controlling the suitability of the working environment. There was no significant difference between isolated species in a single clean room. In all, more than 70% of all isolated microorganisms human were their source. Among the isolates, there were 76.7% Gram-positive bacteria, 8.7% Gram-negative bacteria and 8.2% fungi and molds. The most commonly isolated were the bacteria of the genus Staphylococcus spp., Micrococcus luteus, Acinetobacter and sporogenic Bacillus spp. The first and second hypotheses that the bioluminescence method of measuring the entire ATP is suitable for assessing the purity of the production environment and also suitable for validation and purification control, was confirmed by comparison with conventional microbiological methods. The third hypothesis that the method is sufficiently sensitive for use in clean rooms was confirmed by the fact that the quantities of ATP present in clean rooms were taken samples in the measuring range of equipment. In order to confirm the fourth hypothesis that there is a correlation between the measured quantity of RLU (Relative Luminescent Units) and CFU (Colony Forming Units) for a particular environment, the bioluminescent testing program was performed parallel to microbiological control. In order to evaluate the results and set up the action limits, we first divided the spaces into several meaningful categories, defined the action limits, and then searched for the correlation of methods by individual categories. We initially sought a correlation between CFU and RLU, but we were not able to confirm. The results were then evaluated for relevance and compared the method with respect to performance in finding an inadequate working surface. In two categories of premises, the methods were comparable and in two the ATP method was superior. In rooms with more stringent requirements, we did not confirm characteristic differences between methods, while in rooms with less stringent requirements and non-sterile production we find the new method more sensitive. With used bioluminescence method, we measured the amount of ATP from living cells, which is directly correlated to the CFU and ATP, which is released from the dead microorganisms and from used materials. The latter is an actual indicator of pollution, as a potential medium for microorganisms or a potential source of pyrogens, which is of even greater importance for sterile production than the intracellular or microbial ATP.

Razvoj zdravstvene dejavnosti, ki v središče delovanja postavlja pacienta, je prinesel tudi spremembe in razvoj vloge farmacevta pri zdravljenju z zdravili. Storitve, osnovane na pregledu zdravil (ang. medication review, MR), v zadnjih desetletjih predstavljajo osrednjo vlogo farmacevta pri zdravljenju z zdravili in skrbi za pacienta. V mednarodnem prostoru zasledimo različno oblikovane storitve MR na vseh ravneh zdravstvene dejavnosti, ki pozitivno vplivajo na sodelovanje pacientov pri zdravljenju z zdravili, identifikacijo in reševanje težav, povezanih z zdravili (DRP), ter prispevajo k zniževanju stroškov. Obenem pa, tudi zaradi velike heterogenosti v storitvah in pomanjkljivem opisu le-teh, še ni jasnih dokazov o vplivu na število zapletov, hospitalizacij in smrtnost. V Sloveniji lahko zasledimo številne aktivnosti z elementi MR, ki se izvajajo na različnih ravneh zdravstvene dejavnosti. V Zakonu o lekarniški dejavnosti (ZLD 2016) imamo definirani dve storitvi, osnovani na pregledu zdravil, in sicer pregled uporabe zdravil (PUZ) ter farmakoterapijski pregled (FTP). PUZ se osredotoča na pacienta in njegovo uporabo zdravil in se je razvil na podlagi znanja in izkušenj iz programov farmacevtske skrbi. Razvoj FTP, ki predstavlja celovit pregled pacientovih zdravil z namenom njihove optimizacije, pa se je začel v bolnišnicah, leta 2012 pa še na primarni ravni zdravstvenega sistema v okviru pilotnega projekta na pobudo Zavoda za zdravstveno zavarovanje Slovenije (ZZZS). Od leta 2016 je storitev FTP tudi sistemsko umeščena in financirana s strani ZZZS za izvajanje na primarni ravni zdravstvenega sistema. Obenem sta se obe storitvi razvijali in dokončno standardizirali v skupnem konceptu pod okriljem Lekarniške zbornice Slovenije (LZS). Namen doktorske disertacije je bil ovrednotiti implementacijo in koristi farmacevtskih kognitivnih storitev, osnovanih na pregledu zdravil v Sloveniji. V prvem delu naloge smo se osredotočili na opis farmacevtskih kognitivnih storitev v mednarodnem prostoru, s poudarkom na storitvah MR. V drugem delu pa smo vrednotili implementacijo in koristi obeh storitev MR, prisotnih v slovenskem zdravstvenem sistemu. Opise farmacevtskih kognitivnih storitev, posebno storitev MR, smo najprej ovrednotili s krovnim pregledom literature v dveh bibliografskih bazah. Vključili smo 60 različnih sistematičnih pregledov (SP) in 4 krovne preglede, katerih namen je bil opredeliti, kako kakovostno so bili SP narejeni. SP, vključeni v 4 krovne preglede, so bili večinoma srednje kakovosti, saj tretjina teh ni opredelila kakovosti raziskav pred vključitvijo, poleg tega so bili opisi populacij, intervencij in izidov pomanjkljivi. Zaradi velike heterogenosti pogosto ni bilo mogoče izvesti meta analize (MA). Storitve MR na primarnem nivoju sicer pozitivno vplivajo na uravnavanje nivoja glikiranega hemoglobina, krvnega tlaka, holesterola in drugih dejavnikov tveganja za srčno-žilne zaplete ter omogočajo prepoznavanje DRP. Heterogenost otežuje jasne zaključke o vplivu na humanistične in ekonomske izide. Med kliničnimi izidi ni vpliva na smrtnost, potencialni vpliv na število hospitalizacij pa ima klinični pregled zdravil (tip 3). Rotta in sodelavci so v okviru krovnega pregleda preučili 273 primarnih raziskav in na podlagi identificiranih elementov razvili orodje DEPICT, ki bi lahko pripomoglo k bolj standardiziranemu poročanju elementov storitev in lažjemu kvantificiranju izidov. Nadalje smo v mednarodni presečni raziskavi PRACTISE z uporabo spletnega vprašalnika opredelili dostop, raven implementacije in načine financiranja (remuneracija) farmacevtskih kognitivnih storitev v Evropi, s poudarkom na storitvah MR na primarnem nivoju zdravstvene dejavnosti. V večini sodelujočih držav (n = 34) najdemo osnovne storitve, kot so podajanje informacij o zdravilih, generična zamenjava itd. Nivo implementacije storitev sicer močno variira, polovica držav pa je poročala, da je najpogostejši model financiranja »fee-for-service«. Med naprednimi storitvami se v 55,9 % držav izvaja vsaj ena storitev MR, v sedmih državah imajo le-te tudi visoko raven implementacije. V zunanjih lekarnah se najpogosteje izvajata tip 1 (n = 13) in tip 2a (n = 14), tip 3 pa se izvaja v šestih državah, med njimi v dveh v okviru zdravstvenih domov, saj storitev zahteva dostop do celotne medicinske dokumentacije pacienta. Večina storitev MR tipa 2 in 3 ima sicer postavljene vključitvene kriterije, vendar so ti precej ohlapni (npr. starejši od 65 let). Pri vseh tipih storitev so končne klinične odločitve v rokah zdravnikov. Implementacijo storitve PUZ v slovensko lekarniško prakso smo preverjali v dveh ločenih raziskavah. Najprej smo v fokusni skupini s 7 farmacevti razpravljali, kakšne so izkušnje prvih izvajalcev storitve pri pridobivanju kompetenc in umeščanju storitve v prakso. Po njihovem mnenju so magistri farmacije najbolj kompetentni zdravstveni delavci za izvajanje storitve, ki se osredotoča na izboljšanje pacientovega sodelovanja in razumevanja zdravljenja z zdravili. Prepoznavnost storitve med različnimi deležniki (pacienti, sodelavci in vodstvom, zdravniki ter plačniki) je nizka, zato je bila prepoznana potreba po celostnem pristopu k trženju storitve. Kljub temu da so pacienti po PUZ izražali zadovoljstvo in izkazovali večjo samozavest pri zdravljenju z zdravili, je prav pridobitev in vključitev pacienta predstavljala največji izziv. Velik izziv pa z vidika upravljanja PUZ predstavlja ustrezna organizacija dela v lekarni, ki bi nudila več časa za izvajanje storitve. Koristi storitve PUZ smo ovrednotili v randomizirani kontrolirani raziskavi. Vključeni pacienti so bili randomizirani v kontrolno (K) ali testno (PUZ) skupino, ki je na prvem srečanju prejela PUZ. Po 12 tednih sta obe skupini prišli na ponovno ocenjevanje preiskovanih parametrov. Primarni izid raziskave je bil ovrednotenje sodelovanja z uporabo programske opreme ©Morisky Widget MMAS-8 Software. Uporabili smo generično različico vprašalnika, pri čemer so bili pacienti, glede na doseženo število točk (0–8), opredeljeni kot slabo (do < 6), srednje (od 6 do < 8) ali dobro (8) sodelujoči. Poleg celokupnega smo ovrednotili tudi namerno in nenamerno sodelovanje. Vpliv PUZ smo opredelili kot razliko med PUZ in K po 12 tednih in razvili multivariabilni linearni regresijski model, da smo ocenili učinek PUZ glede na izhodiščno kategorijo sodelovanja, in sicer smo primerjali slabo sodelujoče z združeno kategorijo srednje in dobro sodelujočih. Analizirali smo podatke 153 pacientov s srečanja 1 in 140 pacientov s srečanja 2. Na prvem srečanju je slabo, srednje in dobro sodelovalo 17,6 %, 48,4 % in 34,0 % pacientov. Učinkovitost PUZ se je pokazala pri slabo sodelujočih pacientih, ki so sodelovanje izboljšali za 1,20 točke (95 % CI = 0,16–2,25) v primerjavi s kontrolno skupino (p = 0,025). 0,84 točke je prispevalo izboljšanje namernega sodelovanja (95 % CI = 0,05–1,63 p = 0,038) 0,36 točke pa izboljšanje nenamernega (95 % CI = -0,23–0,95 p = 0,226). Poleg tega so farmacevti v testni skupini prepoznali visok delež dejanskih DRP (41-%), pri čemer sta bili dve tretjini povezani z varnostjo. PUZ je v testni skupini statistično značilno zmanjšal delež dejanskih težav (p = 0,001), delež pacientov z dejanskimi težavami (p < 0,001) ter ogroženost pacientov zaradi dejanskih DRP (p < 0,001). Poleg tega se je značilno zmanjšala zaskrbljenost pacientov glede dolgoročnega jemanja zdravil (p = 0,029). Storitev FTP smo ovrednotili v okviru opazovalne prospektivne raziskave v Zdravstvenem domu Ljubljana (ZD LJ). Namen raziskave je bil pridobiti pogled zdravnikov na implementacijo in koristi storitve FTP s kvalitativnim pristopom (intervjuji). V 38 intervjujih je sodelovalo 24 zdravnikov. Vsebinsko smo rezultate opredelili z Donabedianovim modelom kakovostne zdravstvene oskrbe: struktura, proces, izidi. Ključna farmacevtova kompetenca je poglobljeno in vedno aktualno znanje o zdravilih in farmakoterapiji, kar omogoča pogled na terapijo z druge perspektive. Poleg tega je bilo prepoznano, da pacienti kliničnemu farmacevtu bolj resnicoljubno poročajo o jemanju zdravil, kar je verjetno tudi posledica večje količine časa, ki ga ima klinični farmacevt na voljo za pogovor s pacientom. Ostala temelja strukture sta dober dostop do kliničnega farmacevta in komplementarnost dveh zdravstvenih strok. Med razlogi napotitve je prednjačila polifarmakoterapija, v večji meri zaradi pacientove želje, izražene zdravniku ali referenčni sestri, po manjšem številu zdravil. Razlogi ob napotitvi na zdravnikovo pobudo so bili navadno bolj specifični, npr. fiziološke funkcije. Glavni izziv v procesu FTP predstavljata pomanjkanje časa za prepoznavo primernih pacientov in dodatne obremenitve, ki jih prinaša implementacija ukrepov. Zdravniki se zavedajo, da je treba povečati število napotitev, pri čemer so predlagali na primer definiranje kriterijev za »avtomatske« napotitve, napotovanje pacientov s strani referenčnih sester ipd. Obenem so poudarili, da je FTP novost, ki potrebuje svoj čas, da se uveljavi. Priporočila kliničnega farmacevta so sprejeta v visoki meri (62 %), vendar čas izvedbe priporočil v praksi močno variira. Ko priporočilo zadeva zdravilo, ki je bilo predpisano s strani specialista, zdravniki posredujejo izvid FTP in odločitev o implementaciji priporočila prepustijo specialistom. Opolnomočenje pacienta pri uporabi zdravil je bilo navedeno kot glavna korist za paciente, kar posledično podpira in izboljšuje kakovost zdravstvene oskrbe pacienta s strani zdravnika. Poleg tega je narava številnih priporočil takšna, da so prenosljiva na podobne primere. Družinski zdravniki tako prepoznavajo številne koristi storitve, so z izvajanjem zadovoljni in menijo, da so zelo zadovoljni tudi pacienti. Z obstoječimi raziskavami smo potrdili, da so farmacevtske kognitivne storitve, posebno storitve MR, sicer zelo raznolike, vendar predstavljajo pomembno orodje za kakovostnejšo zdravstveno oskrbo pacientov. Za visokokakovostne dokaze o vplivu storitev na zdravstvene izide potrebujemo kakovostno izvedene raziskave s tarčnimi populacijami pacientov in izidov, ki bodo jasno opisovale potek in elemente intervencij. Z uporabo obstoječih orodij in smernic (npr. DEPICT) je treba še bolj prispevati k že opaznemu trendu kakovostnejšega poročanja. Umeščenost dveh storitev MR uvršča Slovenijo med uspešnejše evropske države na tem področju, vendar je treba izboljšati raven njune implementacije in zagotoviti ustrezne finančne spodbude, predvsem v primeru storitve PUZ. Potrebna je jasnejša opredelitev, katere težave je smiselno naslavljati v okviru posamezne storitve, in na tej podlagi oblikovati ustrezne kazalnike kakovosti, ki bodo omogočali dolgoročno spremljanje učinkovitosti storitev MR tako v Sloveniji kot tudi v mednarodnem prostoru. Developments in patient-oriented healthcare brought changes to the role of the pharmacist in medication treatment. In the last decade, pharmacist-led medication review (MR) services, represent one of the key elements in medication management and patient-centred care. Different MR services on different levels of healthcare are present, with positive impact on adherence, identification of drug-related problems (DRPs) and decreased costs are observed. On the other hand, due to high heterogeneity in services and superficial description of its elements, the evidence regarding health complications, hospitalisation and mortality is inconclusive. Several MR activities are present at different levels of the Slovenian healthcare system. Two services are defined in the Pharmacy Act (2016) – Medicines Use Review service (MUR) and Clinical Medication Review service (CMR). MUR focuses on adherence and proper medicines use, and harmonised previous experiences from pharmaceutical care programmes. CMR is the most comprehensive review with the aim to optimise individual patient’s medicines. Under the initiative of the Health Insurance Institute of Slovenia (HIS), the CMR started as a pilot project in 2012, and was officially implemented as a regular, reimbursed service in primary care in 2016. Concurrently, both services were developed and standardised under the same concept within Slovene Chamber of Pharmacies. The aim of this doctoral thesis was to evaluate the implementation and benefits of MR services in Slovenia. Firstly, we focused on the description of the pharmaceutical cognitive services in international literature, especially MR services. Secondly, we evaluated implementation and benefits of both services performed in Slovenian healthcare. An umbrella review was performed in two bibliographic databases, to analyse descriptions of MR services in international literature. We included 60 systematic reviews and four umbrella reviews which also aimed to assess how well the included systematic reviews were performed. Overall, the systematic reviews (included in the 4 umbrella reviews) were of medium quality, as one third of systematic reviews haven't assessed the quality of primary studies and the description of population, interventions and outcomes was deficient. High heterogeneity was the main reason why meta-analysis was not performed. MR service in primary healthcare positively impacts the levels of glycated haemoglobin, blood pressure, cholesterol and other cardiovascular risk factors as well as enabling identification of DRPs. There is high variation in evidence regarding MR impact on humanistic and economic outcomes. MR does not impact mortality rates, while CMR has a potential to affect hospitalisation rates. After performing an umbrella review, Rotta et al., extracted and evaluated the 273 primary studies for elements of the services. Based on the identified elements they developed the DEPICT toll - a tool to standardise the reporting of pharmaceutical cognitive services and facilitate quantification of outcomes. A cross-sectional study, PRACTISE, was conducted using an online survey to gather data regarding availability, the rate of implementation and the existence of remuneration of pharmacist-led cognitive services in Europe, with a special focus on MR services in primary care. Provision of medicines’ information (94.1%), generic substitution (85.3%), etc are the core services reported as the most widely disseminated. There is wide variation in the implementation level of services, and half of the participating countries mentioned models of remuneration predominantly based on a fee-for-service. MR was the most disseminated among advanced services, with at least one type of MR present in 55.9% countries, and seven countries reporting high implementation levels. Type 1 (n=13) and 2a (n=14) MR services seem to be more feasible to implement in the community pharmacy than type 3 (n=6). In two countries type 3 is performed at the general practitioners (GP) clinics to assure access to clinical data as the essential element of MR type 3. Inclusion criteria are set in the majority of reported type 2 and 3 MR services, however the criteria are very broad (e.g. patients over 65 years). Physicians are the key stakeholders when it comes to clinical decision making in all types of MR services. Implementation of MUR in Slovenian pharmacy practice was evaluated in two separate studies. Firstly, a focus group with 7 pharmacists was performed to gain an in-depth understanding of initial providers experiences with the MUR educational programme to ensure competency for service provision and implementation of MUR into daily practice. Pharmacists’ broad knowledge in pharmacotherapy was emphasised as the basis of quality provision and main advantage in performing MUR in comparison with other healthcare professions. Recognisability of MUR among different stakeholders (patients, co-workers and pharmacy management, physicians, payer) should be improved with a comprehensive approach in marketing of the service. Positive patient feedback was reported, however persuading them to attend MUR presented a challenge. Better management of the service, especially in terms of work organization, would facilitate MUR provision. Secondly, a randomised controlled trial was performed in community pharmacies to compare MUR with standard care. Patients were randomised into either the control or test group, where patients received MUR at visit 1. After 12 weeks all investigated parameters were re-assessed. The study primary outcome was self-reported adherence to multiple medications, assessed by electronic ©Morisky Widget MMAS-8 Software. The questionnaire was adapted for generic use across all prescription medications for regular use. Patients’ scores were classified as follows: < 6 indicates low adherence, 6 to

Well-being is one of the most important factors in whether nurses decide to remain in the nursing profession. This study aims to examine well-being and satisfaction among nurses working in Slovenian hospitals and to identify the related demographic factors.This descriptive cross-sectional study uses standardised instruments. The sample included 640 nurses working in Slovenian hospitals. The difference between individual variables were analysed using the Mann-Whitney and Kruskal-Wallis tests.Nurses self-assessed their satisfaction and well-being as moderate. Forty-seven per cent of nurses were satisfied with their job, 49% assessed their psychological well-being as good, 52% were often exposed to stress at the workplace and 30% were always exposed to stress at the workplace. Levels of job satisfaction (p=0.031), psychological well-being (p=0.029) and subjective well-being (p=0.014) were found to differ significantly according to level of education, while levels of job satisfaction (p=0.005), life satisfaction (p0.001), psychological well-being (p0.001) and subjective well-being (p0.001) were also found to differ according to years of nursing service and from hospital to hospital (p0.001).The key finding of the study is that nurses are moderately satisfied with their work and life and that they display moderate levels of psychological and subjective well-being. Hospitals can be successful and achieve the goals of the organisation if their employees are satisfied with work and enjoy good levels of well-being. Hospital management have to recognise the importance of ensuring that nurses and other employees are satisfied and healthy.Počutje medicinskih sester je eden najpomembnejših dejavnikov odločitve, ali ostanejo zaposlene v zdravstvu ali ne. Namen raziskave je bil ugotoviti stopnjo dobrega počutja in zadovoljstva medicinskih sester, ki delajo v slovenskih bolnišnicah, ter prepoznati nekatere povezane demografske dejavnike.Uporabljena je bila opisna presečna raziskava in standardizirani instrumenti. V vzorec je bilo vključenih 640 medicinskih sester iz slovenskih bolnišnic. Razlike med posameznimi spremenljivkami so bile analizirane s testoma Mann-Whitney in Kruskal-Wallis.Medicinske sestre so samoocenile svoje zadovoljstvo in počutje kot zmerno. 47 % medicinskih sester je zadovoljnih s svojim delom, 49 % pa je svoje psihološko počutje ocenilo kot pozitivno. 52 % medicinskih sester je pogosto in 30 % medicinskih sester je vedno izpostavljenih stresu na delovnem mestu. Glede na stopnjo izobrazbe so bile ugotovljene statistično pomembne razlike v zadovoljstvu z delom (p = 0,031), psihološkem (p = 0,029) in subjektivnem počutju (p = 0,014). Statistično pomembne razlike so bile ugotovljene pri zadovoljstvu z delom (p = 0,005), zadovoljstvu z življenjem (p0,001), psihološkem (p0,001) in subjektivnem počutju (p0,001) glede na leta delovnih izkušenj v zdravstveni negi in upoštevajoč različne bolnišnice (p0,001).Ključna ugotovitev raziskave je zmerno zadovoljstvo z delom in življenjem ter zmerno dobro psihološko in subjektivno počutje medicinskih sester. Bolnišnice so lahko uspešne in dosegajo organizacijske cilje, če so tudi medicinske sestre zadovoljne z delom in se dobro počutijo. Vodstvo v bolnišnicah mora prepoznati pomen skrbi za zadovoljne in zdrave medicinske sestre ter tudi ostale zaposlene v bolnišnici.

Zdravstveni sistem v Sloveniji je bil v letih po osamosvojitvi reformiran. Privatizacija zdravstvenega sistema pa predstavlja velik del izvedenih reform. Zdravstvo se je odprlo zasebnim izvajalcem, prav tako je bil privatizaciji podvržen sistem financiranja. V diplomskem delu nas je zanimalo, ali je privatizacija intenzivneje potekala na področju izvajanja ali financiranja zdravstvenih storitev. V nalogi najprej predstavim koncept države blaginje in zdravstvenega sistema na splošno, nato pa podrobneje opisal privatizacijo, tako z vidika razlage pojava, kot tudi z analizo dosedanjega stanja v Sloveniji. V empiričnem delu, ki je obsegal dve metodi, analizo statističnih podatkov in izvedbo treh intervjujev sem dosedanji razvoj povezal s prihodnjim in na podlagi ugotovitev prišel do sklepa, da so težnje k privatizaciji zdravstva prisotne tako na področju financiranja kot tudi na področju izvajanja, vendar pa je teh teženj občutno več na področju izvajanja zdravstvene dejavnosti. In the years following the independence of Slovenia, healthcare system was reformed. Privatisation represents an important aspect of those reforms. The system was opened up for private practiotionres and financing was partly privatised as well. In this thesis, we were interested whether privatisation was the strongest in the providing services or financing. Firstly, welfare state and healthcare systems in general were presented and later on, privatisation of healthcare as such was presented with the emphasis on the privatisation in Slovenia. Empyrical part of the thesis consisted of two methods (analysis of databases and three structured interviews). Both parts of the empyrical analisys suggested, that tendecies towards privatisation are present in both areas - in the providing services and financing. However, tendencies are stronger in the field of providing healthcare services.

V delu predstavimo doživljanje smrti. Problem današnje medicine, ki smrt primerja z boleznijo, ni toliko v medicini kot v ljudeh, ki medicino predstavljajo, saj se smrti tako kot družba bojijo. Seznanili smo se, kako KKC in Koncilski odloki gledajo na smrt in umiranje.. Teološkemu razumevanju smrti sledi še razlaga iz stare in nove zaveze. Umiranje ni nikoli osebna stvar, ampak vpliva na ljudi, ki so bili povezani s umrlim. In jim dá misliti, kdaj pride njihov čas in kako ga pravilno ali najbolje izrabiti. Če prepoznamo pravi pomen smrti, nam postane vse življenje kot neko srečevanje in učenje minljivosti. V nadaljevanju preidemo k bolj pastoralnim problemom, kako se srečati z umirajočimi, jim pristopiti. Tudi v mnogih bolnišnicah ne komunicirajo z umirajočimi, saj so slednje namenjene bolnim, ki naj bi po določenem času ozdraveli in odšli naprej v življenje. Zato starejši raje umirajo doma kot v bolnišnicah. Paranormalno izkustvo ljudi, ki so umrli in se vrnili nazaj v življenje, vodi do radikalnih sprememb v njihovih življenjih. Smrt tudi za njih ostaja uganka, a se je več ne bojijo. Še naprej živijo svoje življenje in v učenju bistva življenja vidijo glavni pomen. Ugotavljamo, da spominjanje smrti buri duhove in domišljijo že vso človeško zgodovino. Smrt je sama po sebi skrivnost, ki ji ne bomo prišli nikoli do dna, vendar se nam je ni treba bati. Če se že moramo česa bati ob misli na smrt, je to sprejemanje napačnih odločitev v življenju. In this work we present the experience of death. The problem of contemporary medicine lies in its tendency to treat death as a disease however, this has less to do with medicine per se and more with the people who represent it, as they fear death as much as the society does. We have examined the theological understanding of death in the Catechism of the Catholic Church and the Documents of the Second Vatican Council as well as explanations based on both the Old and New Testament of the Bible. Dying is never only a personal thing, as it also affects the people who are close to the dying person. It makes them think about their own death and how to make the best and most productive use of their remaining time. If we recognize the real meaning of death our entire life becomes like some kind of meeting with and learning transience of life. We then discuss pastoral issues, how to minister to the dying. In addition, the staff in many hospitals do not communicate with the dying, given that hospitals are not for the dying but for the sick who will get better after medical treatment and discharged. Hence the elderly prefer to die at home. People who have had paranormal near-death experience and have returned to life are compelled to make radical changes. Death for them remains a puzzle, but they are no longer afraid of it. They live their lives and see in learning about the essence of life its key meaning. We have found that thinking about death stirs the spirits of people and imagination of artists throughout human history. Death is a mystery in and of itself, which we will never be able to fathom, but we do not need to fear it. If we need to fear anything regarding death, it is making wrong decisions in life.

This study was conducted to determine the bacterial colonization of some bacterial groups, including extended–spectrum β-lactamase (ESBLs) producers and methicillin-resistant Staphylococcus aureus (MRSA), on surfaces of the equipment and instruments in patient rooms and other workspaces in three different medical wards. The number of microorganisms on swabs was determined with the colony count method on selective microbiological mediums. The aerobic mesophilic microorganisms were found in 73.5 % out of 102 samples, with the average and maximum values of 2.6 × 102 and 4.6 × 103 colony forming units (CFU) 100 cm-2, respectively. Members of the family Enterobacteriaceae, coagulase positive staphylococci, coagulase-negative staphylococci, and enterococci were detected in 23.4, 31.4, 53.2, and 2.9 % of samples, respectively. The differences in bacterial counts on the surfaces of the psychiatric, oncology, and paediatric wards were statistically significant (P, Ugotavljali smo število in prisotnost nekaterih bakterijskih skupin, vključno z ESBL in MRSA na površinah opreme in instrumentov v bolniških sobah in drugih delovnih prostorih v treh različnih kliničnih oddelkih. Število mikroorganizmov v brisih, odvzetih na izbranih površinah, smo določili z metodo štetja kolonij na selektivnih mikrobioloških gojiščih. Skupno število aerobnih mezofilnih mikroorganizmov smo našli v 73,5 % od 102 vzorcev, s povprečnimi in najvišjimi vrednostmi 2,6 × 102 in 4,6 × 103 CFU 100 cm-2. Predstavnike družine enterobakterij, koagulaza pozitivne stafilokoke, koagulaza negativne stafilokoke in enterokoke smo ugotovili v 23,4, 31,4 53,2 in 2,9 % vzorcev. Število mikroorganizmov na površinah v psihiatričnem oddelku se je statistično značilno (P