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Highlights from this issue

2018-01-19T07:28:34-08:00

We all give lip service to health-related quality of life (HRQOL), but few of us afford it the weight it deserves outside its use as an outcome measure in research. It is defined (very broadly) by the WHO as a ‘child’s goals, expectations, standards or concerns about their overall health and related domains’.1 We receive outcome information like this constantly, but rarely process it fully and given that children from 7 years upwards are capable of reliably reporting their status should, I’m convinced, be doing more. There are a number of scores in use, both general (Peds QL the most widely used) and disease specific ones2 and, given the quality of health (provision and experience) flavour in several of this month’s papers (the theme to my choices) got me thinking how I could incorporate the philosophy (if not the formal scoring) better on a day...




SP1 Medicines optimisation for paediatric patients with learning disability

2018-01-19T07:28:35-08:00

It’s estimated that 2% patients attending our hospital are paediatric patients with learning disabilities (PPLD). PPLD may have multiple co-morbidities leading to complex medication regimens and adherence issues.1 PPLD/carers are relied upon to retain and relay medication regimens to healthcare professionals (HCPs) on admission and across care settings, highlighting the importance of PPLD/carers keeping a current written medications list. Medicines optimisation (MO) is defined as ‘a patient centred approach, focussing on getting the most benefit for patients from their medicines’.2 PPLD may have additional MO needs which HCP’s may not be aware. Aim To determine areas of MO for PPLD. Objectives During the audit period, the objectives were to gain baseline data; to identify if current written medication lists (CWML) were kept whether compliance issues were faced at home and if so, was HCP advice sought, and if problems obtaining medicines from GPs were faced after discharge. Standards 70% of PPLD had a CWML when attending hospital 5% of PPLD had an adherence issue 95% of PPLD with an adherence issue received advice from a HCP 5% of PPLD had issues in obtaining heir medication from their GP on discharge. Method Standards were agreed with specialist paediatric and lead research pharmacists. PPLD were selected using an inclusion/exclusion criteria. A data collection form was developed, piloted, and used by the pre-registration pharmacist to survey patients between 5th-16th/12/16. Data analysis was carried out on Microsoft Excel. This study did not require ethics approval. Results 32% had a CWLM 26% had an adherence issue 40% sought HCP advice for adherence advice 42% had issues with supplies from GP post discharge. 19 PPLD were included in the audit, with an age range of 1–16 years. Medicines were predominantly managed by carers at home, with one adolescent co-managing with their carer. Written medication records included diary, phone notes, repeat prescription, outpatient letter and a drug chart. Adherence problems included poor dissolution of omeprazole tablets and poor taste of levetiracetam tablets. Four patients (21%) required an unplanned intervention by the pharmacist relating to medicines administration issues not picked up during previous consultations. Problems obtaining medicines from GPs included restricted GP’s Formulary and miscommunication. Conclusion No standards were achieved, thus further improvement is required. The short duration and small sample size mean the data represents a snapshot. Recommendations from this audit are: PPLD with complex medication regimens should be encouraged to keep a current written medication record e.g. ‘my medication passport’ (record book) to facilitate medicines reconciliation on transfer of care.3 Education e.g. presentations to HCPs on PPLD compliance issues including administration is paramount for enabling medicines optimisation. Clear, well documented medicines information during transfers of care can reduce medication risk and minimise error. An action plan is currently in progress to improve documentation on discharge. Further work is warranted into why HCP advice is not routinely sought by PPLD/carers. References Jubraj B, Deakin A, Mills S, et al. Pharmacy consultations with patients with learning disabilities. The Pharmaceutical Journal 19 Jan 2016. http://www.pharmaceutical-journal.com/learning/learning-article/pharmacy-consultations-with-patients-with-learning-disabilities/20200330.article Royal Pharmaceutical Society. Medicines optimisation. Helping patients to make the most of medicines. Good Practice Guidance for Healthcare Professionals in England May 2013. https://www.hee.nhs.uk/sites/default/files/documents/helping-patients-make-the-most-of-their-medicines.pdf Barber S, Thakkar K, Marvin V, et al. Evaluation of my medication passport: A patient-completed aide-memoire designed by patients, for patients, to help towards medicines optimisation. BMJ Open 2014;4:e005[...]



SP10 Paracetamol levels following intravenous therapy in neonates less than 28 weeks gestation

2018-01-19T07:28:35-08:00

Introduction

Paracetamol is a mainstay analgesic for neonatal pain and is increasingly used for management of patent ductus arteriosus (PDA) in very premature infants. The BNF for Children (BNFC) gives no dose recommendations for babies <28 weeks gestational age (GA) for analgesia and no recommendations for management of PDA. A recent review1 of current literature only covered babies of ≥32 weeks gestation. We report on the paracetamol levels and safety profiles obtained in thirteen babies of <28 weeks GA, using an extended dosage regimen2 over five days with maximum daily dose of 60 mg/kg/day; twice that recommended by the BNFC for analgesia in infants <32 weeks gestation.

Method

Babies <28 weeks GA, received regular paracetamol for five days intravenously for PDA3 based on the following regimen initially introduced to the unit as part of a clinical trial (PDA TOLERATE)4 babies did not have to participate in the trial to receive paracetamol for PDA.

Regimen: 20 mg/kg loading dose followed by 10 or 12.5 mg/kg QID depending on corrected gestational age (CGA) lower dose for those 23+0 to 25+6 and =7 days at time of treatment, incrementing to a maximum of 15 mg/kg QID. Target paracetamol levels were 1520 mg/l with dose reduction if >25 mg/l and discontinuation if >40 mg/l. Since the major concern about paracetamol is liver toxicity plasma transaminases and bilirubin were obtained before and after (within 96 hours) treatment.

Results

Thirteen babies were treated with paracetamol for PDA. Median gestation at birth was 24+3 weeks (range 23+2–26+2) with a median CGA at treatment of 26+4 weeks (range 25+3–28+0). Median weight was 735 g (range 520 g – 990 g). All babies had paracetamol levels <25 mg/L with a median level of 12.7 mg/L (range 7–24). No dose reductions were required. Serum transaminases and bilirubin were normal before and after treatment. There were no clinical gastrointestinal side effects.

Conclusion

These data suggests these higher doses of paracetamol may be safe for babies of <28 weeks gestation requiring regular dosing, for up to five days, regardless of indication. Paracetamol levels obtained were lower than the target levels set for PDA TOLERATE but consistent with weight based pharmacokinetic models in moderate preterm and term infants in previous studies.4 Given the variation in levels obtained it may be beneficial to monitor paracetamol levels in babies receiving regular dosing.

References

  • Mian P, Knibbe CA, Tibboel D, et al. What is the dose of intravenous paracetamol for pain relief in neonates?Arch Dis Child2017;102:653–654.

  • El-Khuffash A, Jain A, Corcoran D, et al. Efficacy of paracetamol on patent ductus arteriosus closure may be dose dependent: evidence from human and murine studies. Pediatr Res2014;76(3):238–244.

  • Early Treatment Versus Delayed Conservative Treatment of the Patent Ductus Arteriosus (PDA:TOLERATE). ClinicalTrials.gov Identifier USA NCT0195832, NHS HRA UK Clinicaltrials.gov identifier NCT01958320.

  • Allegaert K, Palmer GM, Anderson BJ. The pharmacokinetics of intravenous paracetamol in neonates: Size matters most. Arch Dis Child2011;96:575–5802.




  • P23 Reducing inpatient prescribing errors in paediatric cystic fibrosis patients: a multi-disciplinary quality improvement project

    2018-01-19T07:28:35-08:00

    Aim

  • Assess the incidence, type and severity of prescribing errors

  • Assess the use and efficacy of a pre–existing prescribing aid

  • Reduce the number and severity profile of prescribing errors through increased use of the prescribing aid.

  • Method

    Twenty cystic fibrosis (CF) patients, admitted consecutively to a tertiary paediatric centre, were included in the study. Use of the pre-existing CF prescribing aid and prescribing errors were detected prospectively by daily pharmacist review of electronic drug charts. A doctor and a pharmacist then retrospectively assigned a severity score (A-I), using a standardised tool.1 Ten patients were evaluated initially. Following this, paediatric CF patients were tagged on the electronic prescribing system, creating a pop-up alert to direct prescribers to the CF prescribing aid when those patients’ electronic medicine records were opened.

    Results

    Ten patients (163 medication orders) were evaluated in phase I pre-intervention, and ten patients (157 medication orders) were evaluated in phase II post-intervention.

    In total 127 prescribing errors were recorded. The most common types of prescribing error were: failing to prescribe a patient’s regular medicine (27%); prescribing the wrong formulation (19%); prescribing the wrong dose (14%).

    No errors, in either phase of the study, caused patient harm. The highest severity score in this study was awarded to prescribing errors that reached the patient, did not cause harm but required intervention to preclude harm or required extra monitoring (category D).1

    Throughout both phases, 32% of error containing orders were related to medicines that were not included in the CF prescribing aid, the error rate was comparable in both phases (30%; 35%). These medicines were non-CF specific drugs therefore not appropriate to be included in the prescribing aid. These medication orders were excluded from further pre- and post- intervention analysis.

    In the pre-intervention group, 100 CF medication orders were prescribed. The prescribing aid was used in 42% of orders. 43% of medication orders had at least one prescribing error. 27% of errors were of severity category D.

    In the post-intervention group, 104 CF medication orders were prescribed. The prescribing aid was used in 70% of orders. 27% of medication orders had at least one prescribing error. 15% of errors were of severity category D.

    Conclusion

    Introducing a paediatric CF alert system successfully increased prescriber utilisation of the CF prescribing aid, with subsequent reduction in error rate and severity of CF specific medicines. We are confident that this improvement reflects our intervention, although without in-depth statistical analysis we cannot attribute causality. However, errors still occurred despite the use of the prescribing aid and errors occurred in non-CF specific medicines. A continuous quality improvement approach is being adopted to explore alternative causes for error and further interventions that can be made, with focus on dovetailing inpatient and outpatient prescribing and medication recording. Further study is required in this complex high-risk patient group where polypharmacy is unavoidable.

    Reference

  • National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP index for categorising medication errors2001. http://www.nccmerp.org/types-medication-errors [Accessed: 30/07/2017].




  • P24 Developing a paediatric electronic prescribing system

    2018-01-19T07:28:35-08:00

    Aim

    To develop an electronic prescribing system (EPS), in a tertiary care paediatric hospital.

    Method

    One of the many benefits of electronic prescribing (EP) in secondary care, is the reduction in prescribing error rates.1 However, implementing EP in paediatrics, presents many challenges such as the increased complexity of medication dosing2 and varying doses of drugs depending on indication.2 An EPS was acquired from a local adult secondary care hospital and developed to include a specialist paediatric drug library with clinical decision support. The pharmacy department used a dispensing patient medication record system that was incompatible with the EPS, so the latter had to work side-by- side with the former, as the drug chart. A smaller training team was deployed with external trainers, from the hospital where the system was acquired from and they were enlisted for the pilot.

    Results

    The pilot was launched in April 2017, on the hepatology ward, consisting of 14 beds. All patients that were treated under the hepatology medical and surgical teams were placed on the e-prescribing system and this accounted for 95 patients, from the launch over a period of 3 months. Although the benefits of an EPS became a reality, which included a reduction in medication and administration errors, many drawbacks still existed that hindered a more complete EPS. Certain drugs were found to be missing from the drug library and drug monographs lacked the appropriate clinical decision support for prescribers and administrators alike. This was observed by the sharp rise in incident reporting from 20 reports, in the 3 months prior to the launch, to 55 reports, in the 3 months post-launch. Pharmacy processes, that proved effortless on drug charts and discharge prescriptions, became complex for pharmacists and technicians, as the EPS lacked the necessary features including insufficient message functionality to document patient’s own medicines and supply from pharmacy, discharge prescription alerting and modification of prescriptions once printed. The absence of sufficient and relevant clinical support staff became apparent soon after external trainers returned to their respective bases; with only one support member remaining that had held a clinical position previously. Difficulties quickly became apparent when attempting to explain specific clinical EP functions to non-clinical support staff.

    Conclusion

    In preparation for rollout across the trust, many areas could be improved upon to ensure substantial progress could be made, from the pilot. Developing a more robust system to build and review drug monographs to include both medical and nursing input, from their respective clinical specialities and ensuring that all drugs whether supplied with or without pharmacy involvement are included in the paediatric drug library. Observing the work of pharmacists and other healthcare professionals, to ensure their day-today tasks, on drug charts or discharge prescriptions, are replicated successfully on the EPS. Increased pharmacy involvement in training and support, would benefit the EPS greatly, from a clinical perspective.

    References

  • Franklin G, O’Grady K, Donyai P, Jacklin A, Barber N. The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: A before-and-after study. QualSaf Health Care2007;16:279–84.

  • Johnson KB, Lehmann CU. Council on clinical information technology. Technical report: Electronic prescribing in paediatrics: Toward safer and more effective medication management. Paediatrics2013;131(4):e1350–e1356.




  • P25 Thalidomide administration through a nasogastric tube

    2018-01-19T07:28:35-08:00

    Introduction

    LA, 15 year old female diagnosed with tuberculosis meningitis (TBM). General paediatric team recommended, in combination with existing adjunctive therapy, initiation of Thalidomide, a non-formulary drug.

    Challenge

    Administration of medication, for LA, was via a nasogastric tube. The cytotoxic nature of Thalidomide compounded with the lack of information from Celgene, the manufacturer of the only licensed Thalidomide in the United Kingdom (UK) that supplied oral capsules, provided numerous issues for administration. In addition, TBM was an unlicensed indication for Thalidomide.

    Outcome

    Approval through the Drug and Therapeutics Committee (DTC) was gained. Upon investigating into previous use at the trust, another patient had received Thalidomide for TBM in 2014, this was requested from the same consultant, however on that occurrence there was ease of administration through the oral route so the licensed oral capsules were used. Combined with this previous case and a thorough literature search, a dose was calculated of 200 mg (3 mg/kg once a day), which was agreed by the general paediatrics team. An unlicensed oral tablet formulation was sourced from another manufacturer in the UK. Crushing syringes were sourced to ensure the ‘crushing and dispersing process’ would occur in a closed system. The relevant forms for Thalidomide initiation were completed by the requesting consultant, with the patient and family advised on the appropriate pregnancy prevention measures. An administration guide via feeding tubes was developed for the nursing team. Steps included: wearing gloves and apron, using

    a crushing syringe to crush the Thalidomide tablet in a closed system, drawing 20 ml of water from a medicine pot into the crushing syringe, agitating the syringe to disperse the tablet, using the appropriate ENFIT adaptor to administer the dispersed medication into the feeding tube and disposing of appropriate waste into cytotoxic and clinical waste. Incorporated into this, a safety information leaflet for staff was developed, also for the nursing team, detailing the appropriate ward storage (controlled drugs cupboard) and handling measures, stressing the importance of the teratogenic nature of Thalidomide. The nursing team on the relevant ward, caring for LA, were counselled on and supplied with the guidance that was produced for them. A brief pharmacy guide was developed, detailing to the pharmacy team, the teratogenic nature of Thalidomide along with the special storage conditions (controlled drugs cupboard) and handling measures.

    The pharmacy team were informed of the case and guidance was sent out, to ensure that the correct safety measures were in place. Prior to dispensing, dispensing staff and screening pharmacists were asked to complete a consent form, in order to dispense/screen prescriptions for Thalidomide. Dispensing took place as per cytotoxic medications, with Thalidomide delivered in the relevant yellow sealed bags.

    Moving on

    A Thalidomide policy was drafted and will be submitted to the DTC for approval. Once approved, this will be available for the medical, nursing and pharmacy team, in the future. A pharmacy Thalidomide folder was created, that would house the policy and all the relevant forms required for audit




    P26 An audit of the use of amikacin for early onset sepsis in premature neonates in an inpatient neonatal unit

    2018-01-19T07:28:35-08:00

    Aim

    In April 2017 the Trust updated the Neonatal Infection Guideline due to increasing resistance to gentamicin. Subsequently, the first line aminoglycoside to treat early onset sepsis (EOS) on neonatal units (NNU) for patients ≤32 weeks gestation changed from gentamicin to amikacin.

    Updated guidance recommends prescribing amikacin 15 mg/kg 24 hourly, aiming for trough levels<5 mg/L; however anecdotal reports suggest this results in frequently high trough levels at 24 hours.

    Adherence to current guidelines was audited, to gain insight into the most appropriate dosing interval to use, particularly in extremely low birth weight (<1 kg) and extremely premature neonates (<28 weeks gestation at birth).

    Audit aims

  • 100% of patients prescribed amikacin for EOS adhere to criteria in Neonatal Infection Guideline

  • 100% of patients prescribed amikacin dose of 15 mg/kg

  • 100% of patients prescribed amikacin have a blood level taken at 24 hours (prior to giving second dose)

  • 100% of patients receive further doses of amikacin only when blood levels are <5 mg/L, or under the advice of a pharmacist

  • Method

    Audit standards were derived from hospital policy. All eligible neonates receiving amikacin were included. Neonates on postnatal wards were excluded; they should receive gentamicin for treatment of EOS.

    Prospective data collection was completed across both NNUs at the Trust, which included all neonates that received doses of amikacin from 1st April to 1st August 2017. Data were collected from drug charts and medical records. Data were also collected to account for factors that could contribute to or highlight that the patient suffered from poor renal output; degree of prematurity (gestational age), urine output, urea and electrolytes, any inotropic support, or a significant patent ductus arteriosus. Data were entered onto an Excel spread sheet and were summarised descriptively. The audit was approved locally.

    Results

    A total of 50 neonates received amikacin. 100% adhered to criteria in Neonatal Infection Guideline and 100% prescribed doses of 15 mg/kg. 12 patients (24%) did not have an amikacin level taken at 24 hours, of which 5 (42%) had stopped antibiotics and 7 (58%) had levels taken between 27–36 hours. Of the remaining 38 patients, only 6 (16%) had levels<5 mg/L at 24 hours. Nine (24%) patients then stopped antibiotics at 36 hours. 23 patients had levels taken at 36 hours, of which 17 (74%) could be classed as ‘in range’ at ≤5 mg/L. Two patients received doses despite levels of >5 mg/L. Final results are yet to be fully analysed, however it appears as though there is no direct correlation between gestational age, severity of illness and amikacin level results.

    Conclusion

    Findings suggest it is difficult to pre-determine how a patient will excrete amikacin, even when taking into account gestational age and birth weight; which would support the literature.¹ However, the majority of levels were high at 24 hours and within range by 36 hours, so change in practice from 24 hourly to 36 hourly dosing is recommended. Following implementation of the recommendations, further audit is necessary in one year.

    Reference

  • Allegaert K, Anderson BJ, Cossey V, et al. Limited predictability of amikacin clearance in extreme premature neonates at birth. British Journal of Clinical Pharmacology2005;61:39–48.




  • P27 Impact of new vancomycin dosing and monitoring guideline

    2018-01-19T07:28:35-08:00

    The Neonatal and Paediatric Pharmacists Group (NPPG) released a report which carried out a vancomycin in paediatric audit (VIPA). This report reviewed the effectiveness of currently employed intravenous vancomycin dosing regimens. It stated that British National Formulary for Children (BNFC) vancomycin dosing was not sufficient for achieving the target therapeutic range in typical patients and higher, more frequent dosing is required to reach target levels quicker.1,2 Based on this report, we amended our dosing guidelines to the following empirical starting doses for children with normal or mildly impaired renal function: Infant 1–6 months: 10 mg/kg 6 hourly Infant > 6 month: 15 mg/kg 6 hourly To evaluate if the new guidelines achieve target therapeutic levels quicker without increasing toxicity or incidence of adverse effects an audit was carried out. The results were then compared to an audit carried out in 2009 using the old vancomycin pathway which based doses on BNFC dosing of 15 mg/kg every eight hours.3 The main objectives were to determine the number of patients that achieved target therapeutic range at steady state, and the dose required to achieve this, the time taken to achieve target therapeutic range, the number of patients that achieved levels <10 mg/L (sub-therapeutic) and >20 mg/L (toxic) and the frequency of adverse effects. Method Data was collected for all patients who had been started on vancomycin from 14th September 2016 to 5th December 2016. Using our electronic prescribing system, a daily report identified patients who had vancomycin prescribed. The data collected was compared to the data collected from the 2009 audit. Results 23 patients had been commenced on vancomycin during the audit time frame. 20 of these patients (87%) were started on the correct frequency of 6 hourly dosing, and 13 of these patients (65%) were started on the correct frequency and dose of 15 mg/kg/dose. Of the 13 patients started on the correct dose and frequency, only 6 patients (46%) had their first level taken at the correct time. 4 of these patients (67%) achieved the therapeutic target range of 10–15 mg/L. This has improved from 2009, when an audit completed on the old guidelines showed that 1 patient (7%) reached therapeutic levels without having to adjust dose. No patients’ reached a trough level greater than 20 mg/L and additionally no patients’ had a 50% or greater increase of serum creatinine, suggesting the change to guidelines does not negatively impact on toxicity or acute kidney risk. The mean time to achieve therapeutic dose has decreased from 3.6 days in 2009 to 1.4 days in 2016. There was a correlation between age and vancomycin levels-with the average level for patients between 1–6 months being 10.67 mg/L (therapeutic). Whereas the average vancomycin level for patients over 6 months was 8.14 mg/L (sub- therapeutic). This suggests the new guidelines are more effective for the lower age range group. Conclusion The new guidelines have helped to achieve target levels quicker, with no increase in toxicity. However, there are still areas for improvement for older paediatric patients; reinforcing the idea of aged based dosing. References Cole C, Shepard M. A review of the trust’s paediatric vancomycin guidelines. Neonatal and Paediatric Pharmacists Group2015;1(1):46. http://adc.bmj.com/content/100/6/e1.50 [Accessed: 22nd August 2016]. Nash C, Gooding N, Muller H. Intermittent intravenous vancomycin in children aged over 1 month: Empirical dosing for optimum trough levels. Report to the Neonatal and Paediatric Pharmacist Group January 2016 Neonatal and Paediatric Pharmacists Group2016;1–40. [Accessed: 2nd September 2016]. British National Formulary. 2014th–5th ed. BMJ group, Pharmaceutical Press 2015. [Accessed: 2nd September 2016]. [...]



    P28 Reducing medication errors - a tripartite approach. small steps - better outcomes

    2018-01-19T07:28:35-08:00

    Aim Paediatric medication errors have everyday potential to cause unintended harm.1 Our aim was to reduce paediatric medication errors on a busy general paediatric medical ward. Method A prospective audit was undertaken, using an audit form, looking at the number and severity of medication errors from May 2016 to July 2016. The severity of the errors was graded as per the EQUIP study.2 The results were analysed using Microsoft Excel. Action – A study afternoon was arranged in August 2016 to highlight the common themes behind the medication errors followed by a multidisciplinary brainstorming exercise to gather suggestions on reducing medication errors. An education package was introduced: Medical – all trainees were asked to complete a mandatory online module designed by the Royal College of Paediatrics and Child Health, which provides an overview of need for safe prescription practice in children and common themes leading to errors. Further teaching was provided in departmental teaching meetings and the lead paediatric pharmacist undertook targeted teaching. Nursing – an in house competency package was developed based around the principles of the ‘5 rights’ of medication administration, the Health Board controlled drug policy and the All Wales Policy for Medicines Administration, Recording, Review, Storage and Disposal. All staff were encouraged to complete this package. Through one on one sessions with the practice development nurse, staff were coached to follow the five Rs of Right Drug, Right Dose, Right Time, Right Route, and Right Patient. Pharmacy – Lead pharmacist introduced an education tool as advocated by Meds IQ called Druggle3 in the department, where at the end of the safety huddle the pharmacist discusses medication interventions on a daily basis that may have happened on the ward. Through this tool formative education was provided to junior doctors and nurses. Re–audit – After six months of intensive education, a prospective re–audit was undertaken between December 2016 and February 2017 using an audit form. The results were analysed using Microsoft Excel. Results The results showed that 88.6% (141/159) of children admitted had medication errors. 61.2% (87/141) of errors were minor, 34.7% (49/141) significant, 2.8% (4/141) serious and 1.3% (1/141) potentially lethal. The results of the re-audit showed that 12.1% (57/470) of children had medication errors. 77.2% (44/57) of errors were minor and 22.8% (13/57) significant. There were no serious or potentially lethal errors reported. This showed an overall reduction of 76.5% medication errors in the children admitted following the introduction of the education package. Conclusion The education package through the tripartite approach has achieved a substantial change in the overall rate of prescription errors. We believe medication errors are a significant but preventable cause of harm to children and young people. To ensure this change of practice is sustained we aim to continue the emphasis of education and change management to improve patient safety. References Cass H. Reducing paediatric medication error through quality improvement networks; where evidence meets pragmatism. Arch Dis Child2016;101:414–416. EQUIP final report. http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf [Accessed: 01/08/16]. DRUG-gle (Druggle). http://www.medsiq.org/tool/drug-gle-druggle [Accessed: 01/08/2016]. [...]



    SP4 Can text appeal be used to assess pain control?

    2018-01-19T07:28:35-08:00

    Aims

    Can an automated texting system be used to gather data about analgesia usage after discharge and post-operative pain scores?

    Our opioid analgesic for post-operative pain control had changed from codeine to morphine two years earlier.

    Was this dosing and supply adequate or excessive and how could we assess pain control for patients at home? Some surgeons described their technique as ‘relatively painless’ and had as a consequence chosen to stop prescribing any opioid after surgery.

    Previous audits by post or telephone had achieved a 40% response rate at best. Could we use the smart ‘phones that all parents carry around instead?

    Methods

    We recruited patients undergoing tonsillectomy ± adenoidectomy, and recorded their age, weight, gender, diagnostic indication for surgery and surgical technique.

    After overcoming a few IT challenges and with written consent, parents were texted a series of questions for 10 evenings postoperatively, starting the day following surgery.

    Questions (requiring a single digit response) included the maximum pain score (0–10) experienced, the analgesic drugs administered and any nausea or vomiting (PONV) experienced that day. Responses were stored in a secure database for analysis.

    Results

    33 patients were recruited with1 surgical cancellation. 27/32 (84%) parents responded to texts on ≥5 days.2 Patients with poor responses were excluded.

    Of the 30 studied, 50% were male, with age range 10 months to 15 years, and weight range 6.6 kg to 64 kg. 21 patients had sleep-disordered breathing (SDB) and 14 patients had experienced recurrent tonsillitis, including 5 who also had SDB.

    All children had paracetamol and ibuprofen available, but 4 patients were discharged without morphine. The average pain score ranged from 4.0 on Day 1 to a peak of 5.5 on Day 6 to a minimum of 2 on Day 10.

    In total, 69.2% parents gave their children morphine on one or more days in addition to simple analgesia. The rate of PONV was 30%, unrelated to morphine use.

    Conclusion

    SMS proved very successful for data collection and has great potential for further audit studies.

    Our data shows that pain is a significant problem for up to 10 days post-tonsillectomy and has confirmed the requirement for opioid rescue medication for all patients after discharge.

    We have now re-agreed a standard analgesic regime and staved off any suggestion there was just to recommend that parents buy analgesia.

    References

  • Williams G, et al. The prevalence of pain at home and its consequences in children following two types of short stay surgery: A multicentre observational cohort study. Paediatric Anaesthesia 2015;25:1254–1263.

  • Association of Paediatric Anaesthetists of Great Britain and Ireland. Guidance for the administration of codeine and alternative opioid analgesics in children Nov 2013.




  • P29 An evaluation of the views of adolescent patients with a learning disability and their carers on a medicines information leaflet

    2018-01-19T07:28:35-08:00

    Aim

    This study aims to assess the views of adolescent patients with Learning Disability (APLD) and their carers, on a Medicines Information (MI) leaflet

    Methods

    A questionnaire was devised with 10 questions. Its purpose was to find out if APLD/carers thought the MI leaflet was useful and if they would recommend it. The MI leaflet includes information about preparation before a hospital appointment; problems patients may face with their medicines, medicine interactions and information resources. ‘Full of life’ is a charity that supports families who care for APLD. Patients and carers from the charity were invited to attend a focus group. MI leaflets and questionnaires were distributed for comment, to those who attended. Ethics approval was not required for this study. Data was assessed using Microsoft Excel.

    Results

    20 questionnaires were distributed, 17 completed questionnaires were returned at the end of the session (85% response rate). 70% (n=12) of questionnaires were completed by carers, 24% (n=4) by family members and 1% (n=1) by a patient. 100% (n=17) of carers/patients who read the MI leaflet found it useful. Over 70% (n=12) stated that the leaflet had improved their understanding about medications. All patients/carers would recommend the leaflet to others. Comments about features that patient/carer’s liked included: ‘Very informative’ and ‘I like the colour of the leaflet, the writing is simple to understand’. The patients/carers were asked about ways the leaflet could be improved. Comments included; ‘Laminate the leaflet’, ‘Make the background colour lighter to make the text stand out.’ Limitations included a small sample size, over a short period of time. Patients were sampled from a patient charity focus group, so not representative.

    Conclusion

    APLD may regularly access healthcare services and are faced with challenges. Patients can find it difficult to explain their health conditions and have problems with speech and language structure. This can lead to important medical information being missed.1 UK health organisations have been actively engaged in improving the care for patients with LD.2 The Care Quality Commission (CQC) has resolved to ‘pay particular attention to the needs of people in more vulnerable circumstances’.3 Our multi-disciplinary team have developed a MI leaflet for APLD. Overall, the MI leaflet was received very positively. The extent of an LD can vary significantly; the MI leaflet has been designed for the ‘higher level learners’.

    For other patients, with less capacity, the leaflet would be more suited to be used by carers. Opportunities for future work include a ‘more visual, simplistic’ leaflet for ‘lower level learners’.

    References

  • Jubraj B, Deakin A, Mills S, et al. Pharmacy consultations with patients with learning disabilities. The Pharmaceutical Journal19 Jan 2016. http://www.pharmaceutical-journal.com/learning/learning-article/pharmacy-consultations-with-patients-with-learning-disabilities/20200330.article

  • NHS England. Building the right supportOctober 2015. https://www.england.nhs.uk/wp-content/uploads/2015/10/ld-nat-imp-planoct15.pdf

  • Care Quality Commission. Position statement and action plan for learning disability 2010–2015. http://www.cqc.org.uk/sites/default/files/documents/cqc_learning_disability_position_statement_and_action_plan_0.pdf




  • P31 Compatibility of sildenafil citrate with noradrenaline and vasopressin during simulated y-site administration

    2018-01-19T07:28:35-08:00

    Aim

    Off-label use of IV sildenafil (Revatio) is one of the limited treatment options available in the treatment of Pulmonary Hypertension in the paediatric and neonatal population. The lack of compatibility data on the co-administration of IV sildenafil with other drugs in critical care means a dedicated line is required for sildenafil. However, in critically unwell patients multiple drug infusions are commonly administered and the dedication of an IV line for sildenafil could be problematic and can further increase the risks of adverse events.1,2 Our Lady’s Children’s Hospital Crumlin in Dublin Ireland, identified the following five drugs as critical and commonly encountered in PICU; Adrenaline, Noradrenaline, Vasopressin, Milrinone and Heparin. The aim of this study is to determine the physical and chemical compatibility of Noradrenaline and Vasopressin in combination with Sildenafil.

    Method

    To simulate Y-site conditions the drugs were mixed in a 1:1 ratio as previously demonstrated by Allen et al. 3 Clear glass tubes as specified by the EP, were used to allow for the investigation of compatibility at specific time-points across a 24 hour period at room temperature. Drugs were prepared in accordance with clinical practice; Noradrenaline 60 micrograms/ml, vasopressin 0.4 units/ml and sildenafil 800 micrograms/ml. Different diluents: NaCl 0.9% w/v, Glucose 5% w/v and Glucose 10% w/v were examined. Chemical compatibility was assessed using HPLC and physical by pH determination and visual inspection of contents. Drugs were deemed compatible if concentrations of both remained between 90% and 110% of the original concentration3 and if no signs of physical incompatibility was noted (i.e. pH change, haze or cloudiness).

    Results

    No physical incompatibility was noted between the compounds with stable pH and no visual changes. Concentrations of vasopressin, noradrenaline and sildenafil were all within concentration limits indicating chemical compatibility.

    Conclusion

    The limited and incomplete data presented in the literature for the compatibility of drugs administered via Y-site in combination with sildenafil, makes studies such as this one invaluable to clinicians. The overall aim of this work is to provide a complete compatibility chart of all five drugs identified as critical in combination with Sildenafil at RT and at 37°C. This preliminary data provides a starting point in the investigation of the compatibility of Sildenafil in combination with commonly used ICU drug infusions.

    References

  • Fender RA, Hasselman TE, Wang Y, Harthan AA. Evaluation of the tolerability of intermittent intravenous sildenafil in paediatric patients with pulmonary hypertension. JPPT2016;21(5):419–25.

  • Kelly LK, Porta NFM, Goodman DM, Carroll CL, Steinhorn RH. Inhaled prostacyclin for term infants with persistent pulmonary hypertension refractory to inhaled nitric oxide. JPeds2002;141(6):830–2.

  • Allen LV, Jr., Levinson RS, Phisutsinthop D. Compatibility of various admixtures with secondary additives at Y-injection sites of intravenous administration sets. Am J Hosp Pharm1977;34(9):939–43.




  • P32 Rate of paediatric inpatient and discharge medication prescribing errors

    2018-01-19T07:28:35-08:00

    Aim To assess the documentation of allergies and quantify the rate of prescribing errors (PEs) for inpatient and discharge medications in paediatrics. Method A data collection form was produced and data was collected prospectively by pharmacists for all paediatric patients’ prescribed inpatient and discharge medicines for 1 week during 9 am–5 pm. Electronic charts and allergy status for patients was checked, and all prescribed medicines were screened. If an error was identified, the drug name, type of error and category (wrong drug, dose, route, frequency, duplication etc.) were documented. Medications were screened against the British National Formulary for Children (BNFc), paediatric formularies and trust guidelines. Parenteral nutrition, IV fluids, outpatient and ambulatory medicines were excluded. Results Data was collected for 152 patients with a total of 601 drugs screened. 151 patients (99%) had their allergies with nature of reaction documented as per the trust’s medicines policy. 89 PEs were identified (15% error rate). 89.9% of medicines were prescribed correctly in relation to the drug, dose, frequency, route and formulation. The most common error was wrong dose with 24 (27%) errors; 15 medicines (17%) were prescribed at doses too high. 7 errors occurred with high paracetamol dosing. This potentially occurred due to the dose banding in the BNFc which does not take into consideration dosing for small-for-age children. Wrong route (19 (21%) errors) was the 2nd common error identified. All of these errors related to administration of medicines via enteral feeding tubes. This highlights that careful consideration needs to be given when prescribing medicines for complex patients with feeding tubes. The incidence of drug interaction and contraindication PEs was low. This could be a result of electronic prescribing providing drug interaction alerts. Conclusion PEs can be defined as ‘an unintentional significant reduction in the probability of treatment being timely and effective or increase in the risk of harm when compared with generally accepted practice’.1 PEs in the paediatric population can potentially have a serious impact on patient safety and lead to significant morbidity and mortality. In children, the risk of PEs is three times more likely to occur than in adults.1 One of the key improvements NHS England wants to achieve for 2017/2018 is reducing medication errors across the NHS.2 The trust paediatric clinical quality group have set an objective to have a 40% reduction in PEs by the end of 2017/2018. This audit demonstrates the most prevalent PEs which occurs at the trust and helps to identify the key actions that are needed to maintain patient safety. A paracetamol guideline will be introduced to highlight the difference between dosing-banding and weight-based dosing. Doctor’s training package will be updated to highlight common errors including the importance of thorough medicines reconciliation especially for complex patients with feeding tubes. References Bannan DF, Tully MP. Bundle interventions used to reduce prescribing and administration errors in hospitalised children: A systematic review. Journal of Clinical Pharmacy and Therapeutics2016;41(3):246–255. NHS England. Next steps on the NHS five year forward view [Internet]Mar 2017. https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf [Accessed: 4th August 2017]. [...]



    P34 Quality improvement project aimed at reducing gentamicin errors in neonates

    2018-01-19T07:28:35-08:00

    Aim

    A level 3 tertiary neonatal unit with a capacity of 40 cots providing intensive care, high dependency care, special care & transitional care services, had 18 gentamicin errors reported between January and June 2017, with 84% errors occurring at prescribing and 16% errors in administration. The majority of errors (67%) were due to the complexity of calculating a 36-hourly time interval between doses. A quality improvement project was undertaken with the aim of reducing the number of gentamicin errors on the unit over a 3 month period.

    Method

    An overview of all gentamicin errors were presented to the multidisciplinary team (MDT) with a view of gathering ideas for improvement to ensure a team based approach. An action plan was put in place in line with National Patient Safety Agency (NPSA) recommendations1 and initiated in July 2017 based on a plan-do-study-act (PDSA) model.

    Results

    The PDSA cycles included:

  • a simplified and standardised dosing interval for dosing of gentamicin after the first dose.

  • an updated local monograph with dosing intervals and example prescription.

  • posters displayed in prescribing areas to promote safe and focused prescribing.

  • a feedback session to the full MDT team regarding improvements made and further feedback.

  • ensure compliance with policy by promoting updated guideline & on going error monitoring.

  • consideration of alternative lower risk antibiotic in low risk babies.

  • incorporation of gentamicin prescribing exercise as part of the new doctor induction. The following interventions will be evaluated in 3 months using Datix reported errors before and after implementation. Sequential PDSA cycles will then be conducted for learning and improvement.

  • Conclusion

    A team based approach, using open communication with regular feedback and review is essential in order to improve the quality of prescribing and gain engagement from medical and non-medical prescribing colleagues. Further audit will be undertaken on monthly basis to evaluate the implementation of improvement measures.




    P35 An experience of switching paediatric inflammatory bowel disease patients on infliximab therapy to the biosimilar 'remsima

    2018-01-19T07:28:35-08:00

    Introduction

    The treatment of inflammatory bowel disease (IBD) with anti-tumour necrosis factor (anti-TNF) biologic therapies such as infliximab is expensive, due to the complex development and manufacturing processes involved with the drug. The number of paediatric patients (PP) receiving infliximab at our trust is increasing, leading to NHS cost pressures. The patent for the infliximab reference molecule Remicade has expired and considerably cheaper biosimilar products are now available, such as Remsima. The license for Remsima was based on adult rheumatology patients; this data was then extrapolated across all licenses. There are currently no long term safety studies of Remsima in children.

    A biosimilar drug can be defined as ‘a biotherapeutic product that is similar in terms of quality, safety and efficacy to an already licensed reference biotherapeutic product.’1

    Aim

    We wanted to switch all PP receiving infliximab for IBD at our trust from Remicade to a new biosimilar product – Remsima.

    Method

    The paediatric gastroenterology MDT agreed that all new patients started on infliximab since spring 2016 would be treated with Remsima.

    Information was gathered regarding the safety, switchability and efficacy of Remsima before the change was made.2 For existing patients, we also contacted other trusts who had already made the switch to gain from their experience. Our current patients on Remsima were reviewed, and no problems were reported.

    Existing patients were identified and a letter informing their parent/guardian of why we were changing from Remicade to Remsima was posted. An agreed date after which the switch in treatment would occur allowed any concerns or questions to be addressed on previous visits to the hospital.

    Results

    Overall, the method used was a success: all but one of the identified patients agreed to switch to Remsima – one family refused and the child continues to receive Remicade treatment. All patients on Remsima continue to be monitored closely for adverse reactions or a decline in their disease control. Infliximab levels and antibodies are checked as per local guidelines. Any adverse reactions are reported to the MHRA via the yellow card scheme; Remsima is a black triangle medicine.3

    Conclusion

    Biosimilar medicines present a considerable cost saving to the NHS, and by switching our paediatric IBD patients receiving treatment with infliximab from the reference molecule Remicade to the biosimilar Remsima, the Trust has been able to take advantage of this.

    The saving is substantial and across our 60+patients is somewhere in the region of £250,000 – £2 75 000 a year. This money can be reinvested into the paediatric IBD service to improve patient care. We hope that our experience of switching can be used to support other Trusts in following suit.

    As further biosimilar medications become available, the NHS could continue to benefit by switching patients receiving biologic treatment.




    P36 Streamlining the paediatric pharmacy rheumatology methotrexate monitoring and prescription service

    2018-01-19T07:28:35-08:00

    NHS providers and commissioners ended 2015/2016 with a deficit of £1.85 billion – the largest aggregate deficit in NHS history. One option is to meet this deficit is to improve productivity delivering better value care to help the NHS meet its efficiency targets.1 This is supported by the Carter Report where it stated that pharmacists and clinical pharmacy technicians to spend much more time on clinical pharmacy services than on infrastructure activities or back-office services.2 Aim The aim was to improve the efficiency and cost effectiveness of the paediatric rheumatology service for methotrexate patients requiring therapeutic drug monitoring (TDM) by assigning tasks according to skill mix. Method Value stream mapping (VSM), a lean methodology analysing the current state of a process through work flow mapping and designing a future state for the process in order to improve the process. This was used by the pharmacist and consultant to review the paediatric pharmacy rheumatology patient flow. Each step was determined then reviewed for value to patient care and assigned to the consultant, pharmacist or patient care co-ordinator (PCC) according to skill mix.3 Results 18 different processes were mapped for monitoring a new and current patient’s blood test results and homecare supply. For a new patient registration 5 steps were involved, 8 steps for monitoring a patient’s blood results and 5 steps for homecare supply. In addition, the pharmacist attended the rheumatology clinics when methotrexate patients were booked in. This involved approximately 2 hours every 2 weeks, taking into account that clinics usually did not run on time, to see between 1–3 patients. After VSM it was agreed the consultant would contact the pharmacist when there is a new patient or a current patient requires review. Previously the pharmacist was responsible for contacting patients/parents and carers to remind them of overdue blood tests taking around 45 min a week. With VSM the PCC was identified as the best person to do this. On a weekly basis the pharmacist will access the TDM database and update a list of patients that was overdue blood tests. This list is sent to the consultant and PCC. The PCC will contact the families and update the list with outcomes. Homecare prescriptions were previously organised by the pharmacist for the consultant to sign. The pharmacist continues to ensure the prescriptions are correct in terms of need for supply (liaison with the homecare company, medical documents and consultant for clinical need) and dosage but the PCC liaising with the consultant for administration purposes such as printing of prescriptions and returning prescriptions back to the pharmacist. A standard operating procedure was written to ensure roles and responsibilities are clear. Conclusion This simple and quick exercise has improved the efficiency and cost effectiveness of the service as the most appropriate person now actions each step. Having access to a PCC has saved the pharmacist approximately 1 hour a week and the consultant clinic referral system approximately 2 hours twice a month equating to over 1.5 working days a month. References Dunn P, McKenna H, Murray R. Deficits in the NHS 2016. The Kings Fund available at https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Deficits_in_the_NHS_Kings_Fund_July_2016_1.pdf (Accessed 12.12.17). Lord Carter of Coles. Operational productivity and performance in English NHS acute hospitals: Unwarranted variations. Department of Health. London. Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/[...]



    P37 Audit on the quality of documentation of paediatric prescriptions using electronic prescription charts

    2018-01-19T07:28:35-08:00

    Aim

    The aim of this project is to assess the quality of prescribing on all inpatient prescription charts on the paediatric wards in the hospital against the legal prescribing requirements (as stated in Medicines Act, 1968) and trust prescribing standards (as stated in the hospital's Medicines Management Policy).

    Methods

    Ten audit standards were identified, based on Generic Medical Record Keeping Standards (RCP, 2017), which incorporated all the legal and trust prescribing standards. A data collection tool was then designed.

    A single day prospective prevalence audit was conducted; data was collected on a single day from each of four paediatric wards, using the data collection tool. All staff members were blinded to the standards being assessed.

    Inclusion criteria: all inpatient prescription charts on the paediatric wards and all medicines prescribed on those charts were included (on the single day where data was being collected).

    Exclusion criteria: dietary products, total parenteral nutrition, embolism stockings and chemotherapy.

    Results

    100% compliance was achieved on the majority of patient demographics. 100% compliance was achieved in the majority of standards on prescription item analysis and in all standards for fluids prescriptions. 95% of allergy status were documented and 93% of these included the severity of allergy. 73% compliance was achieved in the documentation of patient weight. Improvement is also needed in documenting indication and duration of anti-microbials, where only 81% and 46% compliance was achieved, respectively.

    Conclusion

    100% compliance was achieved in many standards (in particular in those which are automated on e-prescribing, for example, patient demographics). More attention is needed to specify the patients weight, the allergy status and severity of allergy and the indication and duration of anti-microbials.

    Comparing with previous audits done when the trust used paper charts for prescribing, electronic prescribing has clearly overall increased adherence to legal prescribing requirements and trust standards which is a significant step towards improving the safety of patient care within the NHS.

    The results from this audit have been disseminated to remind current users of common prescribing errors. This was done by presenting the results locally and by emailing all departmental staff with the results.

    Recommendations from this audit include to ensure that all members of staff that have access to electronic prescribing receive the necessary training prior to starting working.

    Recommendations also include to discuss with pharmacy whether it is possible to make it compulsory to enter weight and allergy status prior to prescribing, with an option for omission in emergency situations.




    P38 An audit to assess influenza vaccination uptake amongst asthmatic children in a city in the northwest of england

    2018-01-19T07:28:35-08:00

    Aims

    One of the most common triggers of asthma exacerbations are respiratory tract infections such as influenza.1 Furthermore, the National Review of Asthma Deaths (NRAD) in 2014 linked inappropriate prescribing in primary care to patient deaths.1 The primary aim of this study was to assess the uptake of the influenza vaccine in asthmatic children in Liverpool during the 2016–2017 flu season. The secondary aim of this audit was to assess if children are being prescribed asthma medication in accordance with BTS guidelines.2

    Method

    The inclusion criteria for this retrospective study included children aged 16 and under, diagnosed with asthma and registered at a GP surgery within the Liverpool Care Commissioning Group (CCG). The practice managers at all 95 surgeries were invited to participate in this study via email. Participation included conducting a search using EMIS (Egton Medical Information Systems) to produce a paediatric asthma list that included the child’s age, gender, their current regular asthma medication, if and when the child had received the flu vaccination. Depending on their preference, the surgeries either completed an audit form or generated an anonymous EMIS search report. These documents were collected from the surgery by the researcher or returned via email. The data was analysed in SPSS using the chi-square test to determine if there were any significant associations between demographics, flu vaccination status and compliance to guidelines.

    Results

    Information regarding flu vaccination was collected for 475 patients from seven surgeries. In total 148 (31.2%) children had received the flu vaccination during the 2016–2017 influenza season. Being registered at a GP surgery in an area of low deprivation and being aged 5 and under was associated with higher vaccination rates (p<0.05).

    Data containing current asthma treatment was obtained for 297 patients. In total 194 of those (65.3%) prescriptions followed current BTS guidelines. The most common reasons for not following BTS guidelines were patients being prescribed salbutamol monotherapy or no asthma medication at all. Being male and registered at a GP surgery in an area of low deprivation was associated with being prescribed asthma medication in accordance to guidelines (p<0.05).

    Conclusion

    The uptake of the influenza vaccine in asthmatic children in Liverpool during the 2016–2017 flu season was very low (31.2%). The majority of children were prescribed regular asthma medications in line with BTS guidelines, although there are still multiple instances of poor prescribing practice. The results suggest that age, gender and deprivation level according to postcode affect whether a child’s medication will follow BTS guidelines or whether the child will be vaccinated. More research is required to fully establish these links.

    References

  • Royal College of Physicians. National Review of Asthma Deaths 2014. Available at https://www.rcplondon.ac.uk/projects/national-review-asthma-deaths (Accessed 12.12.17).

  • British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma 2016. Available at https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/ (Accessed 12.12.17).




  • P39 Continuous vancomycin dosing: an audit and evaluation

    2018-01-19T07:28:35-08:00

    Aims

    Late onset sepsis is a major cause of morbidity and mortality within the field of neonatology, with coagulase- negative staphylococci being the most commonly reported pathogens. Due to staphylococcal resistance patterns vancomycin is an essential therapeutic agent. Its efficacy correlates directly with duration of bacterial exposure at therapeutic levels. Some studies have suggested that continuous infusion achieves quicker and more sustained therapeutic levels than traditional intermittent dosing. Continuous dosing was introduced in our neonatal units in September 2015. This piece of work audits adherence to local prescribing and monitoring guidance whilst assessing the effectiveness of the new continuous regimes.

    Method

    All infants commenced on continuous vancomycin over a six month period were included. Cases were identified via pharmacy records and data collected retrospectively and prospectively. Key areas were: loading and initial continuous doses, therapeutic drug monitoring (TDM), time spent in therapeutic range and the associated effects of gestation and baseline creatinine. Adverse effects were also considered. Data was analysed using Excel and Prism.

    Results

    45 treatment episodes were eligible for analysis. Corrected gestation ranged from 24+5 to 41+6. Mean weight was 1450 g and mean duration of therapy 6.5 days. Loading, initial continuous dosing and TDM were generally carried out in line with local guidelines. Regarding the first level measured after commencement of the continuous regime; 9% of levels with continuous infusion were subtherapeutic. A previous audit of intermittent vancomycin dosing showed that 50% of first levels were subtherapeutic. Statistically there was a weak correlation between creatinine level prior to commencement of continuous vancomycin and the first level. Of all 298 levels measured 56% were therapeutic, 19% were supratherapeutic and 25% subtherapeutic. Time spent in therapeutic range was comparable across the range of gestational groups.

    Conclusion

    Continuous vancomycin dosing showed promising results in this population. Adherence to local guidelines in terms of prescribing and monitoring was good. The time taken to reach therapeutic range was shorter than previously achieved with intermittent dosing. Maintaining levels with this therapeutic range was also seen to be favourable. More detailed analysis of our results suggests that our dosing guidance is adjusted correctly to take into account important variables in vancomycin pharmacokinetics such as corrected gestational age and renal function. No adverse effects specific to vancomycin were noted during the course of this work.




    P40 Impact of an educational intervention program on handwritten prescription errors in a paediatric critical care unit

    2018-01-19T07:28:35-08:00

    Introduction Medication errors are a major source of concern in the paediatric intensive care unit (PCCU).1 To further improve medication safety on PCCU, we aim to reduce handwritten prescription errors by implementing an educational intervention program and auditing its impact. Aim To audit handwritten prescription errors on the paediatric critical care unit before and after an educational error reduction intervention. Method Handwritten prescriptions were audited by the ward pharmacist for 2 months prior to the intervention. Errors were defined as incorrect dose for age, weight, indication, incorrect route, missing information, wrong prescription chart, inappropriate prescription. These errors were also categorised by prescriber, medication and nature of the error. Prescribers were alerted to errors at time of identification and explained how to correctly prescribe this in future. After 2 months, an educational intervention program was implemented on the same group of prescribers. This consisted of individual reminders for prescribers who made the error during the pre-intervention audit period and a summary of the most important errors emailed to all PCCU registrars. The audit continued after the intervention for another 2 weeks and collected information on errors as well as prescriptions written correctly for previously incorrectly prescribed medications. Result Of the 11 prescription errors found in the pre- intervention audit, 9 were by PCCU prescribers. 5 of these errors were selected for dissemination to all prescribers via email based on severity and appropriateness. One of these were prescribed correctly after the intervention by the original prescriber who made the error. The other 4 prescription issues in the email were not encountered during the 2 week audit post intervention. 2 prescription errors were made in the post interventional audit, all by PCCU prescribers. One of these errors were targeted in the educational intervention, and made by a prescriber who did not make the original error in the pre-intervention audit. Conclusion and discussions The educational intervention implemented has shown to prevent the prescriber from making the same mistake on one occasion. However, it did not show that it could prevent all other prescribers from making the same error. This could be due to the error being made 1 day after the email summary was sent and the prescribers might not have all read it at the time. Limitations of this audit include the different length of pre and post intervention audit which made comparison of errors numbers difficult. The pre-intervention audit was extended due to small numbers of prescription errors made, which could be related to fewer prescriptions written during the quieter summer season. This resulted in a shortened post intervention audit period. Greater prescriber experience could also have an effect on errors and future audits with other groups of prescribers with no educational intervention may help account for this influence. The implementation of this education intervention has shown mixed effects on reducing handwritten prescription errors on PCCU. We aim to replicate this intervention and audit for a longer period during the winter season to further examine its effects. Reference Potts AL, Barr FE, Gregory DF, Wright L, Patel NR. Computerised physician order entry and medication errors in a paediatric critical care unit. Pediat2004;113(1):59–63. [...]



    SP5 A study exploring the opinions and attitudes of medical staff towards pharmacist independent prescribing in a neonatal intensive care unit

    2018-01-19T07:28:35-08:00

    Aim Existing published literature supports the implementation of pharmacist independent prescribing (PIP). A positive impact on patient care1 has been reported, with an encouraging response from patients2 and other healthcare professionals when asked about their views. There have also been reported patient safety benefits from PIP in secondary care.3 There is a gap in the literature regarding the utilisation of PIP in neonatal practice. The views of neonatal pharmacists across the UK towards PIP have been considered4 but to date there has been no research published on the opinions of medical staff about PIP in Neonatal Intensive Care Units (NICU). This study aimed to explore the opinions and attitudes of medical staff towards PIP in NICU, identifying any barriers and facilitators to the current service. Method Semi-structured interviews were conducted with a purposively selected sample of senior registrars and consultants working within NICU. An interview schedule was developed, assessed for content validity and then piloted with two initial interviews (total interviews=10). Interviews were digitally recorded then transcribed verbatim. Framework Analysis principles were applied to data analysis. Ethics approval was granted by Robert Gordon University. Results Participants displayed a positive attitude towards PIP, stating that it has been beneficial to the overall service provided in NICU. Improved patient safety, shared workload for medical staff and increased efficiency in prescribing were cited as important benefits. Collaborative working as a multi-disciplinary team when making prescribing decisions for the patient was noted to be essential, as was ensuring junior medical staff still receive the prescribing experience required for them to be competent prescribers. Although medical staff reported no concerns with PIP, lack of a service at weekends and PIP being limited by multiple concomitant ward rounds were identified barriers. The interpersonal skills and knowledge displayed by neonatal pharmacist prescribers, acceptance by the medical team and positivity towards new developments shown by all staff were highlighted as important facilitators. Conclusion All participants were fully supportive of the PIP service provided in NICU. Utilising the knowledge and skills of pharmacist prescribers has improved the efficiency and quality of prescribing in the unit and has had a positive impact on patient care. References Latter S, Blekinsopp A, Smith A, et al. Evaluation of nurse and pharmacist independent prescribing 2010. London: University of Southampton. http://eprints.soton.ac.uk/184777/2/ENPIPexecsummary.pdf [accessed: 2016 August 17]. Tinelli M, Blekinsopp A, Later S, et al. Survey of patients‘ experiences and perceptions of care provided by nurse and pharmacist independent prescribers in primary care. Health Expectations 2013;18:1241–1255. Baqir W, Crehan O, Murray R, et al. Pharmacist prescribing within a UK NHS hospital trust: Nature and extent of prescribing, and prevalence of errors. Eur J Hosp Pharm 2015;22:79–82. Mulholland PJ. Pharmacists as non-medical prescribers; what role can they play? The evidence in a neonatal intensive care unit. E J Hosp Pharm 2014;21:335–338. [...]



    P41 An audit of the screening and treatment of uveitis in children with juvenile idiopathic arthritis (jia) at a paediatric tertiary centre

    2018-01-19T07:28:35-08:00

    Aim The primary objective of this study was to audit the centre’s and its satellite clinics’ compliance with the British Society for Paediatric and Adolescent Rheumatology (BSPAR) and the Royal College of Ophthalmology (RCO) uveitis screening guidelines. The secondary objective of the study was to compare the centre’s compliance with the treatment guidelines of JIA and uveitis, as recommended by NHS England and following results from the SYCAMORE trial. Method The clinical records of 54 patients recruited from the Childhood Arthritis Prospective Study (CAPS) were analysed over a six-week period. The data collected included patient demographics, JIA sub-type, date of referral and uveitis screening, presence of uveitis and treatment (if applicable), and details of medication prescribed for JIA. Information was gathered from the centre’s EPMA system and paper records, and was requested from the satellite centres if needed. The raw data was inputted into the statistical software SPSS v23 to evaluate the categorical data. Chi-squared tests were performed on the data to detect any potential correlation between various demographic variables and primary and secondary outcomes. Results 92.6% (50/54) of patients were referred for uveitis screening after being diagnosed with JIA. For 3 (5.6%) patients there was no evidence of referral and for 1 (1.9%) patient the documentation was not clear. 90% (45/50) of the referred patients were screened for uveitis. For the remaining 5 (10%) patients, there was no documentation of whether screening had taken place. The compliance of ophthalmology departments with the BSPAR/RCO guidelines was poor with only 17.8% (8/45) of patients being screened within six weeks of the ophthalmology referral. 8.9% of patients (4/45) were diagnosed with uveitis and 2 of these patients received adalimumab as part of the treatment regime. The treatment for JIA was documented for 75.9% (41/54) of patients and all treatments (100%) were in line with the current recommendations from NHS England. Statistical correlations could not be identified due to the low numbers of patients. Conclusion The BSPAR/RCO guidelines suggest that all new patients are to be screened as soon as possible, no longer than 6 weeks after referral.1 As uveitis is commonly an asymptomatic condition2 with severe complications such as blindness,3 routine screening is imperative. Overall, the compliance of the tertiary care centre and satellite clinics with the BSPAR/RCO guidelines was poor. Immediate changes are required to improve patient care, focusing on facilitating sharing of documentation and communication between the primary centre and its satellite clinics. Raising awareness of targets recommended by BSPAR/RCO to emphasise the importance of timely uveitis screening via regional training days should take place. Ensuring all junior staff that might see JIA patients in clinic are aware of the need of uveitis screening via offering structured training during their rotation is recommended. References BSPAR: Guidelines for Screening for Uveitis in Juvenile Idiopathic Arthritis (JIA ) (1st ed.)6 Oct 2016. Engelhard SB, Asima B, Ashvini RK. Causes of uveitis in children without juvenile idiopathic arthritis. Clinical Ophthalmology2015;9:1121–1128. Juvenile Idiopathic Arthritis (JIA). Cincinnatichildrens.org. N.p., 5 Oct 2016. [...]



    P42 The impact of a change to hospital guidelines on prescribing practices of nebulised 3% w/v 'hypertonic saline

    2018-01-19T07:28:35-08:00

    Aims

    Recent conclusive evidence has suggested that, contrary to previous limited evidence, there is no benefit to the use of 3% hypertonic saline (3% HS) in the treatment of bronchiolitis in infants.1,2 This led to a change in the clinical guideline during the 2015/2016 bronchiolitis season. We hypothesised that the use of hypertonic saline was preventing the use of other un-necessary treatments and that inappropriate prescribing would increase following the advice not to give hypertonic saline.

    The primary aim of the study was to determine if the removal of 3% hypertonic saline from the institutional clinical guideline would result in reduced prescribing patterns. A secondary aim was to evaluate the overall prescribing compliance with the guideline including in the prescribing of antibiotics and bronchodilators, and identify if the change in the clinical guideline impacted the prescribing of other agents in children admitted with a diagnosis of bronchiolitis.

    Methods

    Data on medical treatments and hospital outcomes were prospectively collected on all infants in the 2015/2016 season both before and after the change in guideline. Details of all medicines prescribed on the patients Medication Record particularly bronchodilators, antimicrobials and inhaled agents were collected. Patient demographics were collected from medical notes. Results were analysed using chi square and Mann Whitney in Excel and Stata.

    Results

    128 children (86 before, 42 after the change in guideline) were recruited to the study. Baseline demographics were similar except for a higher proportion of children with RSV in the pre-group. Overall guideline compliance was achieved by 2 infants pre, and 3 infants post guideline change (4%). The use of hypertonic saline decreased significantly after the change in guideline but did not cease (90% pre, 71% post p<0.01). Bronchodilators were used in one in 4 infants and antibiotics in one in 3 infants, and there was no significant difference in these rates before or after the change in guidelines.

    Conclusion

    The change to the guideline reduced the use of 3%HS, however overall guideline compliance in children with bronchiolitis is poor. Hypertonic saline use decreased when the guideline changed but a significant portion of children before and after the guideline change received medications not indicated in the treatment of bronchiolitis, including bronchodilators and antibiotics. It appears that it remains difficult to ‘do nothing’ for bronchiolitis. Poor clinical practice remains and education of clinical staff is necessary in this regard.

    References

  • Guidance: Bronchiolitis in children: diagnosis and management, NICE (NG9) Published date: June 2015.

  • Silver AH, Esteban-Cruciani N, Azzarone G, et al. 3% hypertonic saline versus normal saline in inpatient bronchiolitis: A randomised controlled trial. Paediatrics2015;136:1036–1043.




  • SP6 Use of glibenclamide in neonatal diabetes

    2018-01-19T07:28:35-08:00

    Situation JJ is a neonate born with diabetes due to a suspected KCNJ11 mutation which was later confirmed by genetic testing. The KCNJ11 mutation results in the patient being unable to produce insulin due to an inability to close a potassium dependent ATP channel required for the process. Prior to the administration of an intravenous (IV) insulin infusion JJ’s blood glucose levels reached 17 mmol/L. A plan for long term management of this patient’s condition was required before discharge. Background Untreated or uncontrolled neonatal diabetes can result in severe complications such as reduced renal function or intra-ventricular haemorrhage therefore prompt and continued management of blood glucose levels is essential. Outcome Options for JJ’s long term management were considered by the paediatric diabetes multi-disciplinary team (MDT) following the suggestion of use of a sulphonylurea. Prior experience of its use had been found to be the most effective therapy in patients with KCNJ11 mutations.1 Continuation of IV therapy was unsuitable because of poor IV access and challenging monitoring requirements. Subcutaneous therapy was dismissed due to variability and unpredictability of pharmacokinetics and pain on injection in a neonate. Expert advice was sought from Exeter University specialists who recommended the use of glibenclamide specifically. A literature search described its use in a 3 month old at a dose of 0.1 mg/kg/day.1 A reference discussed 3 extemporaneous formulations and demonstrated chemical stability2 but with rapid settling and poor dose uniformity. It was decided that an extemporaneous product was also unsuitable due to potential for variation of formulation between primary and secondary care. As glibenclamide is insoluble in water a suspension was required to ensure uniformity of distribution of the drug and therefore reliable dosing. An acceptable product manufactured by a specials company as a suspension was identified and product information requested to determine potential suitability for use in neonates with regards to excipients. JJ was discharged at 2 weeks of age with frequent planned review by the MDT. His blood glucose levels were stable, although there were some instances of hypoglycaemia post-dose and hyperglycaemia pre-dose therefore the dose was eventually reduced to 0.04 mg/kg/day and split into 3 divided doses to prevent this. He remains well, is showing normal growth and development with stable blood glucose results since the dose amendment. Lessons learnt Sulphonylureas close the potassium dependent channel independently of ATP that patients with KCNJ11 mutations cannot. This results in the ability of these patients to produce insulin endogenously whereas previously they would have required full insulin supplementation. Prompt and clear MDT communication and the use of glibenclamide in a neonate enabled discharge due to improved blood glucose levels within 48 hours of initiation. References Pearson ER, et al. Switching from insulin to oral sulfonylureas in patients with diabetes due to Kir6.2 mutation. New England Journal of Medicine 2006;355(5):467–77. Di Folco U, et al. Stability of three different galenic liquid formulations compounded from tablet containing glibenclamide. Journal of Nutritional Therapeutics 2012;1:152–160. [...]



    SP7 Development of a paediatric triage tool for use by pharmacists to aid clinical prioritisation of patients and delivery of pharmaceutical care

    2018-01-19T07:28:35-08:00

    Aim

    To gain consensus from an expert paediatric and neonatal clinical pharmacist panel on criteria to be applied in the design of a triage tool for use in paediatric and neonatal settings.

    Methods

    The ‘Delphi Technique’1 was used to identify pharmaceutical care issues, known as criteria, to aid in the prioritisation and targeting of pharmacists’ time to deliver pharmaceutical care to paediatric and neonatal patients. Criteria based ’statements’ based upon the literature2–4 were developed and put into a questionnaire format which was distributed amongst members of the Scottish Neonatal and Paediatric Pharmacy Group (SNAPP). A five point Likert-scale and option for free hand text was used to record responses. Responses were analysed and used to modify subsequent rounds of the Delphi technique.

    Results

    18 criteria were identified for use in the triage tool and were largely characterised upon time of review. Criteria pertaining to daily review included patients prescribed high risk medicines, psychotropic medication, continuous infusions and those with severe, acute kidney injury. Criteria pertaining to 48-hourly review included patients with stable chronic renal failure and mild kidney injury. Criteria for 72-hourly review included stable patients with no acute issues.

    Conclusion

    A triage tool to aid pharmaceutical prioritisation in paediatric and neonatal patients has been developed and will be piloted for use in clinical practice.

    References

  • McMillian S, King M, Tully M. How to use the nominal group and Delphi techniques. Int J Clin Pharm 2016;38:655–622.

  • Abbas S. The sensitivity of the paediatric triage tool in identifying care issues. Abstracts from 21st Annual Conference of Neonatal and Paediatric Pharmacists Group, NPPG, 2015.

  • Cottrell R, Caldwell M, Jardine G. Developing and implementing a pharmacy risk screening tool. Hospital Pharmacy Europe (Magazine) 2013;71.

  • Stuart Z. The development and pilot evaluation of referral tool for pharmacy technicians to use within a paediatric medical acute receiving unit 2014. MSc Project submitted to the University of Strathclyde.




  • SP8 Introducing a ward-based pharmacy technician to support the administration of paediatric medicines: an evaluation of parent and staff perspectives

    2018-01-19T07:28:35-08:00

    Aim To determine the impact of replacing a nurse with a ward-based pharmacy technician as the second checker, in the process of administering medicines to children in hospital by exploring the views and experiences of parents and staff involved in the change in practice. Method Having undertaken additional in-house training, a pharmacy technician replaced the second nurse on medication ward rounds (second checker) for 10 months over two wards. This took place on a neuro-medical ward and a medical specialty ward. The pharmacy technician undertook roles relating to medicines administration, including: attending day time medicine administration rounds; checking accuracy and appropriateness of prescriptions; preparing/administering prescribed medicines; independently undertaking dosage calculations; recording the administration of medicines. Using their specialist knowledge and skills, the role aimed to improve medicines optimisation for patients and their families during their inpatient stay. Research staff conducted semi-structured qualitative interviews with parents of patients who were administered medicines during the study period (n=12) and with staff involved with the change in practice, as well as an interview with the pharmacy technician themselves after leaving each ward. Families were recruited from the two wards. Semi-structured interviews with staff (n=14) gathered data on the perspectives and experiences of the contribution of the ward-based pharmacy technician across two wards. An exploratory approach was taken using Thematic Analysis.1 Interviews were transcribed verbatim and anonymised. The research team familiarised themselves with transcripts by reading in full and generating initial codes using text from the data. Themes were generated and discussed between the team to produce an overall story of the analysis. Interviews were conducted over a 4 month period. Results Parents discussed the importance of communication about their child’s medicines in hospital. Some parents were aware of the pharmacy technician’s role as second checker. Parents recognised the benefits of the technician’s background and expertise, and their contribution to the ward team. Fourteen staff interviews were conducted including the ward based pharmacy technician (after leaving each ward), the Chief Pharmacist, the Director of Nursing, a Ward Manager, Nursing and Pharmacy staff. Staff commented how the pharmacy technician provided a link between the Pharmacy and Nursing teams, alleviating nurses of administration duties and allowing them to spend more time with patients. The role was also seen as educational allowing for nurses to refresh their knowledge on medication storage procedures and alternative methods of administration. Conclusion To the research team’s knowledge, this is the first study of its kind to assess the potential benefits of introducing a ward-based pharmacy technician as a second checker. This novel role extension releases nursing staff time to undertake more patient-centred nursing duties. In addition, the specialist knowledge of the pharmacy technician at the point of medicine administration had a positive impact on medicines optimisation for children in hospital, providing more effective administration of medicines and contributing to wider patient safety in paediatric settings. Although further evaluation is requi[...]



    SP9 Moving away from traditional asthma exacerbation therapies - single dose dexamethasone

    2018-01-19T07:28:35-08:00

    Introduction Prednisolone has been the mainstay of treatment for acute exacerbation of asthma for some time. Course length is usually between 3–5 days depending on severity and patient history. However, treatment is not without its issues. Preparations suitable for use by young children such as 5 mg soluble tablets have poor palatability and are very expensive. In addition to this, several patients at the trust have been noted to have poor compliance with treatment once discharged from ED. Many feel better after the first dose and because parents ‘don’t want their children to be on unnecessary steroids’ the course of treatment is not completed. This can lead to re-attendance due to reoccurrence of symptoms and additional steroid treatment. With the introduction of liquid preparations such as the orange flavoured 10 mg/ml solution from focus pharmaceuticals palatability has improved as well as a slightly lower price. However, the issue of poor compliance still remains. Method A group of health care professionals reviewed evidence relating to the management of acute asthma over the course of one day. The purpose being that no one was to bring their personal opinions to the event and should only consider the evidence being presented. One of the main points to be considered was steroid use in exacerbations. Evidence was presented that a single dose of dexamethasone at a dose of 0.6 mg/kg (max 16 mg) was non inferior to 3 days of prednisolone at an age appropriate dose.1 Some children, in particular those who are admitted to hospital with more severe exacerbations, may require a further dose 24 hours later (making it equivalent to 5 days of treatment). The group voted unanimously in favour of the change and the change was approved by the trust CGEG committee. It was agreed that after 6 months the change would be audited to see how effective the change has been. Results Patient lists were obtained from the trust informatics system and initial review of data was performed by junior pharmacist. Unfortunately data from the system was poor and generated only small numbers. Further review of patient notes was done by author. It showed that in 6 months 146 patients attended accident and emergency receiving dexamethasone as treatment for acute exacerbation of asthma. In these children, 42 were admitted to the hospital with duration of stay between 1–7 days. Of these children only 12 received a second dose of dexamethasone based on consultant review of need. In those receiving a single dose their re-attendance rate was the same as that of those who received prednisolone in the preceding 6 months (8% Dex vs 9% Pred). Conclusion A single dose of dexamethasone was shown to be non-inferior to comparable dose of prednisolone in the trusts patients. The switch removed the issue of non-completion of treatment as well as reducing the cost associated with treatment with a predicted £24 000 saving for the ED predicted in the first 12 months of use. Further work is needed to see how this treatment affects adrenal function long term. Reference Keeney RL, et al. Dexamethasone for acute asthma exacerbations in children: A meta-analysis. Paediatrics Mar 2014;133(3). [...]



    SP11 Family integrated care: a way forward for medicines optimisation on the special care baby unit

    2018-01-19T07:28:35-08:00

    Introduction Family Integrated Care (FIC) is a new model of care within the neonatal unit that aims to empower parents to take a more active role in caring for their newborn child. FIC has been shown to have many positive effects including reducing length of admission.1 FIC involves building a relationship with parents and training them to deliver many aspects of care to their newborn baby whilst on the neonatal unit. As neonatal units implement FIC, this presents both a challenge and opportunity to pharmacy. Many aspects of FIC complement medicines optimisation, as described by the Royal Pharmaceutical Society,2 such as understanding the patient and parent experience. The aim of this project was to plan, design and implement a clinical pharmacy service on the local neonatal units by combining FIC and medicines optimisation. Methods Guidelines regarding medicines optimisation were reviewed along with existing local policies. Parents and members of the multi-professional team (MDT) involved in FIC where then interviewed. Open-ended questions were used to establish what their needs were and what pharmacy could do to support them. This information was then used to finalise the methods for delivering medicines optimisation. Results The interviews provided useful feedback for how medicines optimisation should be delivered. Parents were very receptive to learning more about their child’s medicines and being trained to administer them. They felt it would give them a better understanding of why a medicine was being used and also prepare them for discharge. In addition, they also wanted to be provided with written information and a structured training plan to reduce anxiety and build confidence. Nursing staff wanted documentation to ensure that there would be accountability for who was responsible for administering medicines. They also highlighted that there needed to be a process to communicate prescription changes to parents. Managers asked that processes complied with medicines governance policies. Pharmacists worked closely alongside the FIC project team to agree on the processes for medicines optimisation. This included drop-in group teaching sessions on medicines every fortnight for parents, regular medication reviews by pharmacists with parents at the cotside, using the hospital self-administration policy to assess parent competency to administer medicines, using one stop dispensing to supply medicines, and producing an information leaflet for parents. Conclusion FIC has provided an excellent opportunity to plan and develop a neonatal clinical pharmacy service for the future. Specifically, to tailor it so that parents and patients are at the centre. Involving parents in this process provided valuable information and resulted in changes to the delivery of care. Empowering parents to become more involved with medicines, supported by pharmacy, has the potential to benefit everyone. References O’Brien K, Bracht M, Macdonell K, et al. A pilot cohort analytic study of family integrated care in a Canadian neonatal intensive care unit. BMC Pregnancy and Childbirth2013;13(Suppl. 1):S12. Royal Pharmaceutical Society. Medicines optimisation: Helping patients to make the most of medicines2013. London: Royal Pharmaceutical Society. [...]



    P01 A retrospective observational study of the use of rasburicase within a tertiary paediatric oncology centre

    2018-01-19T07:28:35-08:00

    Rasburicase is used for the treatment and prophylaxis of hyperuricaemia in patients with haematological malignancy at high risk of tumour lysis syndrome (TLS). It is licensed in both adults and children at a dose of 0.2 mg/kg/day for up to 7 days. In adults off label dosing of 3 mg stat is being used for the prophylaxis of TLS and, whilst not licensed, has been recommended by the British Society for Haematology (BSH) TLS guidelines (Jones et al., 2015). Consequently this has been translated to paediatric use, with our centre using a dose of 0.2 mg/kg (max 3 mg). The aim of this audit is to establish the current prescribing practice for rasburicase within this paediatric oncology centre and ascertain whether its use is in line with BSH recommendations for TLS management in paediatrics. Method Paediatric patients who had received rasburicase within the previous 12 months were identified via the pharmacy dispensing system. For each patient data was collated from the medical notes, drug chart and blood results. The patient’s risk for TLS was defined, the intended use of rasburicase (treatment or prophylaxis) was established and each patient was assessed for laboratory and clinical signs of TLS according to BSH guidelines. Results Eleven patients received rasburicase within the previous twelve months. Six were initiated on prophylactic dosing versus five on treatment. Seven out of eleven patients were classed as high risk of TLS, three of which were given a single prophylactic dose of rasburicase and four given treatment. Of the three high risk patients who received rasburicase prophylaxis, one was capped at 3 mg and subsequently converted to treatment due to escalating TLS. This patient received allopurinol concurrently with rasburicase. Three non high risk patients received prophylactic rasburicase. Two showed laboratory signs of TLS and received capped doses of 3 mg. One patient had no access for bloods and was given an uncapped prophylactic dose. The average number of prophylactic doses given per patient was 1.8. Five out of six patients who received treatment rasburicase showed laboratory signs of TLS. The average duration was 4.1 days. Conclusion The results show inconsistency in the prescribing of rasburicase at this paediatric oncology centre, particularly for TLS prophylaxis. Some patients received capped prophylactic dosing whilst others did not. BSH guidance does not recommend a dose cap of 3 mg in paediatrics due to a lack of evidence whereas the local guideline does. One patient received both allopurinol and rasburicase – the BSH guidance advises this as unnecessary with the potential to reduce the efficacy of rasburicase. TLS treatment with rasburicase was more consistent with five out of six patients being treated in line with BSH guidance and the product license. Reference Jones GL, Will A, Jackson GH, Webb NJ, Rule S. Guidelines for the management of tumour lysis syndrome in adults and children with haematological malignancies on behalf of the British committee for standards in haematology. Br J Haematol2015;169:661–671. [...]



    P02 An audit of vancomycin dosing in the neonatal units

    2018-01-19T07:28:35-08:00

    Aim To audit the prescribing and monitoring of vancomycin in the neonatal units against the local guideline. The neonatal vancomycin guideline has never been audited. Anecdotally, prescribing and monitoring of this drug is challenging, with pharmacists frequently being asked for advice. The guideline has two ranges depending on which bacteria are being treated, 10–15 mg/L and 15–20 mg/L. The initial dosing frequency is different for babies greater than 10 days of age. Method Data on vancomycin doses, levels, time taken, patient age, weight and renal function, were collected on a data collection form prospectively, from prescriptions and clinical records for all babies on vancomycin on between 17/10/2016 and 16/12/2016. Patients were followed throughout their stay; some had repeated courses. The audit was approved locally. Audit standards were derived from the guideline, with 100% adherence aimed for. Data were entered onto an Excel spreadsheet. Results Data was collected from 19 patients, 28 vancomycin courses and 31 vancomycin levels. 28/28 (100%) prescriptions had the correct initial dose. In one neonate the dose changed from 12 to 8 hourly when they were 10 days old. This change led to a high level. 13/15 (87%) had the level taken at the correct time. Two were taken 2–3 hours late. Thirteen courses were stopped before requiring levels. 19/31 levels (62%) were within a safe range (10–20 mg/L). All 6 levels>20 mg/L had the next dose held and the level repeated. In two of these cases there was no subsequent dose reduction causing further high levels. In one case a further vancomycin course was prescribed as per guidelines, with no consideration of previous levels, a high level was recorded again. Two levels between 15–20 mg/L were considered too high; a dose was omitted, resulting in two sub-therapeutic levels (below 10 mg/L). Of the other four low levels, three were not acted upon appropriately – no dose or frequency increase, one was acted on correctly with a dose increase. Conclusion The size of the data set was small but the descriptive findings are interesting. The initial aspects of the guideline are adhered to with all doses prescribed correctly. High levels resulted in doses being held and levels repeated but subsequent actions were suboptimal. Levels appeared to be viewed in isolation and so either no change or an incorrect change was made causing further avoidable high levels. Often low levels were not acted upon appropriately. It is possible that there is limited understanding of pharmacokinetic principles underpinning the adjustment of doses. Changes have been made to the guidelines including a statement that the doses are the initial starting doses only and that dose adjustments are based on levels not age. The different ranges caused confusion and given that the specific bacteria presentmay not be known when initiating treatment, the guidelines have been amended to clarify the safe range of vancomycin to be 10–20 mg/L. Teaching sessions with worked examples will be held with all prescribers and nursing staff. [...]



    P03 An evaluation of medication errors in paediatric cytotoxic chemotherapy, prior to electronic prescribing implementation

    2018-01-19T07:28:35-08:00

    Aim To investigate the incidence and severity of errors in the prescribing and administration of paediatric cancer chemotherapy, in order to improve the safety of current practice and use as a comparison following the introduction of electronic prescribing. Method In a children’s cancer Principal Treatment Centre, the following was reviewed: Incident reports relating to cancer chemotherapy for the previous three years. The Trust’s incident reporting database was searched using location for each ward/out–patient area, as well as searching by keywords for ‘chemo’, ‘chemotherapy’ and individual drug names. Interventions made by paediatric oncology pharmacists screening chemotherapy prescriptions for the most recent eight month period. These were recorded by the pharmacists directly onto a spreadsheet at the time of screening the prescription. All amendments/clarifications to prescriptions were asked to be recorded, regardless of whether they required the action of e.g. the prescriber. Each report was categorised according to type and severity by a multi-disciplinary team comprising a senior nurse, paediatriconcology consultant and a senior paediatric oncology pharmacist. Activity was defined as the number of chemotherapy items manufactured for the children’s cancer wards. Incidents and pharmacist interventions were categorised as follows: Chemotherapy Medication (Incorrect drug, dose, durations or routes of administration) Roadmap errors (Incorrect protocol selected or sequencing of cycles within a protocol) Supportive care measures (Incorrect IV fluids or supportive medications) Timing errors (incorrect day/time) Pharmacy errors (dispensing or labelling) Clerical errors (Incorrect identifying data e.g. patient number) Communication/process errors (e.g. Failure to collect medication/expired chemotherapy) Pharmaceutical (e.g. amending fluids to ensure stability) No error – but clarification needed adding to prescription Harm was categorised using the American NCC MERP scale.1 Results Incident reports over the three year period were at rates of 0.37%, 0.48% and 0.43% respectively as a proportion of the number of items of chemotherapy manufactured. Communication and pharmacy errors were the most common. There is a trend towards an increasing rate of incidents with the potential to cause harm year on year. Rates of pharmacy interventions were variable and difficult to analyse. The most common errors intercepted were chemotherapy and roadmap errors. There were a large number of uncategorised interventions, mostly relating to pharmaceutical manufacture. Conclusion The incident report rates are comparable with those found in the literature.2 Undertaking this investigation raised awareness of medication safety within the paediatric oncology service. Concurrent work looked at which errors would and would not be mitigated by the introduction of electronic prescribing. These data will be used as a comparison for studies once electronic prescribing is established. References National Coordinating Council for Medication Error Reporting and Prevention. Index for Categorising Medication Errors2001. http://www.nccmerp.org/sites/default/files/indexBW2001-06-12.pdf [...]



    P04 Exploring the competency assessment required for pharmacists to undertake systemic anti-cancer therapy verification in paediatric haematology oncology

    2018-01-19T07:28:35-08:00

    Aim To gain consensus on the content required to develop a training plan and competency assessment tool for pharmacists to undertake systemic anti-cancer therapy (SACT) verification for paediatric haematology oncology patients; a high risk clinical pharmacy area.1 Method A two-stage Delphi style questionnaire, using a five point Likert scale, was distributed to pharmacists in the UK and Ireland.2 The extent to which they agreed or disagreed with a series of statements was rated. These statements covered seven key elements3: essential requirements for pharmacists working in cancer care areas; governance and patient safety; cancer biology and SACT; initiation of treatment; toxicity and oncological emergencies; prescription verification; and clinical application and assessment. Consensus of opinion with each statement was set at ≥70% agreement.4 Where there was failure of agreement in round one, this was reassessed in round two. Results The majority of respondents operated in principal treatment centres and had >5 years work experience. Consensus was reached in 80.3% of the statements asked in round one. Consensus was not reached on whether a pharmacist would be required to be aware of the Lanksy and Karnofsky performance scales, whether they would be required to explain how to manage some oncological emergencies and how it was best to assess competence for the pharmacist’s clinical application of knowledge. These areas were further explored in round two and consensus was reached in 66.7% of the statements. Consensus was reached on how best to assess the competence of a pharmacist new to this high-risk area and advanced level pharmacist would need to demonstrate awareness of the Lanksy and Karnosfky performance scales. However, consensus was not reached on whether they would be able to explain and how to manage superior vena cava obstruction and increased intracranial pressure. Conclusion A strong consensus was reached on the competency assessment required for pharmacists to undertake SACT verification in paediatric haematology oncology, and how best to conduct this assessment. These findings will be used to develop a training framework and evidence pack to traininexperienced pharmacists entering this high-risk clinical area. It will be distributed to the Children’s Cancer and Leukaemia Group principal treatment centres and members of Neonatal Paediatric Pharmacy Group – Paediatric Oncology Pharmacists sub-group. References Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci2012;7:37. Carrington C, Weir J, Smith P. The development of a competency framework for pharmacists providing cancer services. J Oncol Pharm Pract2011;17(3):168–78. Meyers RS, Costello-Curtin J. Implementing a paediatric pharmacy educational program for health-system pharmacists. Am J Pharm Educ2011;75(10):205. Powell C. The Delphi technique: Myths and realities. J Adv Nurs2003;41(4):376–82. [...]



    P05 A service review of the palivizumab outpatient rsv prophylaxis clinic

    2018-01-19T07:28:35-08:00

    Aim As the administration of palivizumab, shown to provide effective passive prophylaxis to respiratory syncytial virus (RSV) and reduce RSV-related hospitalisation in high-risk infants,1 will continue and remains a high-cost drug, it is important to ensure continual review of the outpatient immunisation clinic. The aim of this study was to investigate if clinical outcome was affected by the current dosing schedule and suggest possible measures to improve the efficiency and cost-effectiveness of the clinic. Method The following data were collected for all patients receiving palivizumab between October 2014 and March 2015; indication for treatment, weight at start and end of treatment, details of dose and date given and reasons for discontinuation or transfer of treatment. The following were then calculated from the data; rates of RSV- related hospitalisation, median dose administered (mg/kg) basedon predicted weight (using the standardised neonatal and infant close monitoring growth charts) to ascertain under or over dosing and current and additional costs of any suggested service developments. A two-tailed paired student t-test was used to assess statistical significance. The study methodology was approved by the local research ethics committee and the Caldicott guardian. Results 0.98% and 3.92% of all patients receiving palivizumab contracted RSV with an underlying cardiac condition or prematurity respectively. Median weight gain over the 5 month period was 37.18% (n=54, p<0.001). Median dose (mg/kg) based on predicted weight was 15.6, 15, 14.29, 13.79, 13.33 from clinic 1 to 5 respectively. Median percentage difference from target dose of 15 mg/kg was 4.01, 0,–4.76, –8.05,–11.1 from clinic 1 to 5 respectively. The estimated incremental cost for weighing and dosing each patient at every clinic was £7,077.66 (6.3%). Conclusion Patients receiving palivizumab for RSV prophylaxis require to be weighed more frequently and subsequently prescribed a more appropriate dose at the outpatient immunisation clinic if optimal doses are to be achieved. However, the sub-optimal dosing did not affect RSV-related hospitalisation rate when compared with rates in current literature2 and further work is required to model mean trough concentrations achieved from the median doses administered.3 The increased cost of prescribing a dose based on increased weight can be justified due to expected improvementin patient outcome and potential reduction in RSV-related hospitalisation. As pharmacists are being actively encouraged to become independent prescribers within the next few years,4 it would be an ideal opportunity to utilise this resource in an effort to potentially improve prescribing efficiency within the clinic and provide additional benefits such as improved parent/carer education. References The Impact-RSV Study Group. Palivizumab, a humanised respiratory syncytial virus monoclonal antibody, reduces hospitalisation from respiratory syncytial virus infection in high-risk infants. Paediatrics1998;102:531–537. Deshpande SA, Northern V. Community child health, public health, and epidemiology: The clinical and health economic burden of respirator[...]



    P06 A study to assess the effectiveness of vitamin d supplementation in paediatric cystic fibrosis patients

    2018-01-19T07:28:35-08:00

    Aims Patients with cystic fibrosis (CF) require supplementation of fat-soluble vitamins due to the effects of the disease on the pancreas and the resulting inability of absorb fat effectively.1 The study aimed to assess the effectiveness of current of vitamin D supplementation to achieve adequate serum Vitamin D (25OHD) levels in paediatric CF patients.2 Secondly, this study assessed the effectiveness of ‘Stoss’ therapy (a high dose vitamin D therapy administered every three months) as an alternative to daily vitamin D supplementation for patients with known poor compliance.3 Methods Vitamin D doses and serum 25OHD levels between January and December 2016 were reviewed for paediatric CF patients at a UK centre. Data was collected for 138 paediatric patients. The ‘clinical record summary’ system was used to extract the data which included age, hospital number, weight in 2015 and 2016, 25OHD levels from 2015 and 2016, vitamin D dose before each level and pancreatic status. Data was entered onto Statistical Package for the Social Sciences (SPSS) system for analysis. A paired T-test was conducted to ascertain if there was a significant difference in weekly/kg doses between patients that were sufficient (25OHD>50 nmol/L) and insufficient (25OHD<50 nmol/L). Results Data was collected for a total of 138 patients. The data from only 70 patients was analysed when investigating the first objective, as all other patients did not have 25OHD levels available for both 2015 and 2016. A further five patients wereexcluded and analysed seperately due to receiving Stoss therapy. The weekly Vitamin D dose range was very wide for both years with 43% (n=40) of patients requiring additional vitamin D in addition to Aquadeks (CF multivitamin preparation). There was no significant difference in Vitamin D doses between patients with sufficient and insufficient 25OHD levels. This was thecase for both 2015 (p=0.432) and 2016 (p=0.192). The daily supplementation doses were successful at maintaining vitamin D sufficiency for 83% of patients in 2015 and 93% in 2016. Out of the 5 patients who received ‘Stoss’ therapy, 3 had an increase in 25OHD levels. However, only one of the patients had a significant increase leading to sufficient 25OHD levels. In 2 cases there was actually a 60%–68% decrease in 25OHD levels, which lead to these patients developing vitamin D deficiency. Conclusion This study was useful in determining the effectiveness of current Vitamin D dosing. The results suggest that patients having insufficient 25OHD levels may not be due to an inadequacy of doses provided in the current guideline, as there was no significant difference in dose between patients with sufficient and insufficient 25OHD levels. Given the patient group, the difference could be attributable to a lack of compliance to daily therapies in the patients with insufficient 25OHD levels or even differences in individual responses to therapy. In this sample, ‘Stoss’ therapy is not effective in maintaining sufficient 25OHD levels. Although the data for this part of the study was very limited, it identifies a need to investiga[...]



    P07 Development of a decision-making tool to aid implementation of the national guideline on extended-interval gentamicin in neonates

    2018-01-19T07:28:35-08:00

    Aim

    To implement the dosing and monitoring recommendations of the national gentamicin guideline for neonates1 and the British National Formulary (BNF) for Children.2 To assist the transition with the development of a decision-making flowchart.

    Method

    A baseline audit (n=30) was conducted in the neonatal unit (NICU) to assess compliance with the national guideline and highlight areas to target for change and improvement. A new local gentamicin guideline and a decision-making flowchart were developed and implemented. Education on the new practices was provided. A post-implementation audit (n=28) was performed to assess compliance and measure changes. The new dosage regimen involved giving a dose of 5 mg/kg every 36 hours to neonates with a postnatal age (PNA) of <7 days, and 5 mg/kg every 24 hours to those with a PNA of ≥7 days. The previous dosing regimen was based on body-weight and postmenstrual age (PMA), and used 24 hourly dosing. Pre-dose (trough) levels were taken before the 2nd dose in both guidelines.

    Results

    Following the development and implementation of the new guideline and flowchart, compliance with the dosing regimen recommended in the national guideline and in the BNF for Children increased by 83% (10% versus 93%, P<0.001). Compliance with local guidance was reduced by 7% (100% versus 93%, p<0.2). Monitoring of renal function (U and Es/creatinine) increased by 35% (46% versus 81%, p<0.01).

    Conclusion

    Decision-making tools can improve dosing and monitoring practices and standardise care.3 Introduction of a flowchart led to increased monitoring of renal function in neonates treated with gentamicin. Medication errors post- implementation were due to medical staff following the old dosing regimen, based on PMA, for premature neonates. There were no administration errors resulting from the change from 24 hourly dosing to 36 hourly dosing. Change can be associated with an increased risk of medication errors as staff adjust to new practices. Continued education is required to support staff through the change process.

    References

  • Gentamicin Improvement Project Group. Gentamicin: Guidelines for once daily usage in adult and paediatric settings2016. [Available: www.rcpi.ie].

  • Paediatric Formulary Committee. BNF for children 2016 20172016. UK: BMJ Group, Pharmaceutical Press and RCPCH Publications Ltd.

  • Fonzo-Christe C, Guignard B, Zaugg C, et al. Impact of clinical decision support guidelines on therapeutic drug monitoring of gentamicin in newborns. Ther Drug Monit2014;36(5):656–62.




  • P08 Does the neonatal continuous intravenous infusion prescription chart reflect the medication the baby is actually receiving?

    2018-01-19T07:28:35-08:00

    Aim The aim of this audit was to examine whether the continuous intravenous infusion prescription chart is an accurate reflection of the infusions the baby is actually receiving. The neonatal continuous infusion prescription charts were redesigned six months ago to reduce the prescribing burden of rewriting all continuous infusions on the Neonatal Intensive Care Unit (NICU) on a daily basis. On the new charts the prescription remains valid until it is crossed off or for a maximum period of 7 days. The impression of the pharmacist however is that prescribers are not always crossing off the prescription when they stop an infusion. Method Data collection commenced in June 2017 by the Lead Neonatal Pharmacist. All babies on NICU on a Monday for a period of 4 weeks were included. The continuous infusion prescription chart was compared to the continuous infusions actually being administered to each baby and the corresponding numbers recorded. Any prescriptions identified that were no longer being administered but had not been crossed off were marked as ‘inactive’ by the pharmacist and the nurse/prescriber made aware. The results were fed back the same day to the nurses/prescribers on shift by the pharmacist and cascaded to the Lead Neonatal Consultant for Medication Safety and Chair of Drug and Therapeutics Committee for dissemination to the wider neonatal team via email. A poster was designed and displayed on the ward to highlight the results. Results Week 1–107 infusions prescribed; 60 being administered (47 (44%) inactive prescriptions) Week 2–27 infusions prescribed; 21 being administered (6 (22%) inactive prescriptions) Week 3–26 infusions prescribed, 24 being administered (2 (8%) inactive prescriptions) Week 4–23 infusions prescribed, 20 being administered (3 (13%) inactive prescriptions) Conclusion The continuous intravenous infusion prescription chart was not an accurate reflection of the medications a baby was actually receiving at the start of the audit; 44% of infusions prescribed were no longer being administered. The number of prescriptions crossed off when the decision was taken to stop the infusion improved throughout the 4 week period. By week 3 the majority of continuous infusion prescription charts matched the medications the baby was actually receiving. Both the infusions identified as inactive in week 3 and 2 out of the 3 infusions in week 4 were inotropes that had been slowly weaned to stop following the decision to stop on the ward round. These prescriptions were unable to be crossed off at the time the decision was made to stop the infusion, as the intention was to wean to stop; however the nurses informed the pharmacist conducting the audit that the prescribers were aware the infusions had now stopped and were due to come back and cross off the prescriptions. This audit demonstrates that a regular pharmacist presence highlighting issues with prescribing practice can drive change quite quickly and promote compliance with good prescribing procedures. Training has been incorporated in to the doctor induction programme and neonata[...]



    SP2 A study to assess how nurses use the paediatric medusa monographs and identify areas for improvement

    2018-01-19T07:28:35-08:00

    Aim The Injectable Medicines Guide (IMG), also known as Medusa, is a web-based resource which contains over 400 monographs for medicines given by the intravenous (IV) route.1 Since 2013 paediatric specific monographs have been developed and many of these are now used in paediatric units across the UK. The aim of this study was to assess the usability of the Medusa monographs from the paediatric nurse perspective. To understand how paediatric nurses use monographs and what problems they encounter. To assess nurses perceptions of the monographs and the website. To identify areas for improvement. Method A mixed-mode survey was distributed to paediatric nursing staff, both electronically using Qualtrics and by paper. Data was collected over a 2 week study period across 3 paediatric hospitals. The survey consisted of open and closed questions. Open questions allowed comprehensive responses to be obtained and capture any areas of improvement. Likert scale based questions were used in order to determine the perceived importance of issues highlighted in a previous orientation study. SPSS statistical software was used for analysis of the survey. Results Sixty nurses completed the survey and 34 nurses (60%) stated that they were overall satisfied with the monographs. Of the 60 participants, 54 (90%) reported that they use Medusa as a first line resource for IV administration but only 34 (58%) use it prior to every intravenous medicine they administer. Most nurses access the monographs on line (n=50; 86%), followed by using a printed copy in the patient record (n=33; 57%). Looking at the content of the monographs, 36 nurses (61%) agreed that the dilution instructions were clear while 17 (29%) disagreed. Only 32 nurses (54%) felt that the reconstitution instructions were clear and 33 nurses (56%) agreed that the monographs were easy to follow. Eleven nurses (19%) found the monographs too detailed, and 20 nurses (34%) found Medusa more time-consuming to use compared to other resources. This was thought to be due to problems with access and the need to refer to other resources, such as local guidelines and the BNFc as dosage information is not provided in the monographs. The majority (n=50, 84%) of nurses agreed that the monographs should include dosage information. The distribution of this was hospital dependent, with the hospital providing the highest number of survey responses having used in house monographs with dose information previously. Conclusion The Medusa monographs are used as a first line resource for IV administration and received an overall satisfaction rate of 60% by nurses. While the clarity of instructions, layout and the time-consuming nature of the monographs are definite areas of improvement, the greatest concern is the exclusion of medication doses. Improvements in layout are needed based on this feedback and easier access to dosing information should be considered. Reference Keeling S, Burfield R. The injectable medicines guide website. Br J Nurs 2010;19:25–28. [...]



    P09 'theres no place like home: reducing paediatric discharge steps

    2018-01-19T07:28:35-08:00

    Aim

    To determine the efficiency of dispensing paediatric discharges at dispensary vs ward level.

    Method

    A data collection form was designed for use during a two-phase audit. During the first week of data collection, the turnaround time of dispensing discharges in the dispensary was collected. In the second week, the turnaround time of dispensing discharges at ward level on the paediatric ward was recorded.

    The dispensary standard of a 60 min turnaround for medium priority discharges1 was used for both weeks. Medical, surgical and ENT prescriptions were all included in the audit.

    Results

    Information relating to 23 discharges was collected during week one at dispensary level. In week 2, 21 discharges were assessed.

    When assessing the minimum and maximum time taken from when a patient was informed of their discharge to medications being given, there was a reduction of 98 min when completed at ward level for minimum time and 75 min for the maximum time.

    The average turnaround time for dispensing prescriptions was 94 min at dispensary level and 26 min at ward level. Only 57% of discharges completed in the dispensary met the standard turnaround time of 60 min compared to 100% completed at ward level. Discharge prescription turnaround time was decreased by 72% when completed at ward level.

    In total sixteen discharge steps were identified using the traditional dispensary based method for discharges. These ranged from the patient being told they can go home on the ward round to the prescription being written and sent to pharmacy, and finally returned to the ward for transfer to the patient.

    The process of dispensing discharges at ward level enabled a reduction of 50% of the sixteen steps, subsequently expediting the discharge process.

    Conclusion

    When discharges were completed at ward level standards were met 100% of the time and a reduction in eight discharge steps was accomplished. Thus highlighting that a ward level dispensing service is necessary on the paediatric ward in this District General Hospital.

    Reference

  • Wallace K. Prescription Tracker System (PTS). Patient services District General Hospital2014.




  • P10 Evaluation of existing line-locking practice in central venous catheters of paediatric patients on home parenteral nutrition

    2018-01-19T07:28:35-08:00

    Aim To review current line-locking practice of central venous catheters (CVCs) to reduce catheter related blood stream infections (CRBSIs) and preserve line integrity in paediatric patients on home parenteral nutrition (HPN), with the secondary aim of producing a concise, evidence-based guideline for use in this cohort and inpatient PN patients as well. Method All 19 paediatric HPN patients were reviewed retrospectively over 6 months (January–June 2017). Data was collected from clinic letters, HPN prescriptions and blood cultures. Information gathered per patient: Line lock(s) Infective episode(s) CVC replacement(s) Establishment of current practice: All patients use TaurolockTM first-line. If CVC is stiff or stops bleeding back switch to TauroLockTM-Hep100. Should problems persist introduce alcohol 70% on alternate days or alone if recurrent infections occur on TaurolockTM. Blocked CVCs are instilled with urokinase or alteplase and CVC replaced if unsuccessful. Results 18/19 patients were prescribed line locks as per above practice. One patient is prescribed heparin 10units/ml – due to a documented TauroLockTM allergy – and remained infection- free throughout. 7 infections occurred overall in 6 patients with 13 patients infection-free. 2.2 infections/1000 catheter days occurred in patients on TauroLockTM with 2 patients requiring CVC changes due to infection and broken CVC respectively. 1 infection/1000 catheter days occurred on TauroLockTM- Hep100 with 2 CVC changes required due to occlusion. 11 infections/1000 catheter days occurred in 1 patient on daily alcohol 70%, although result validity is uncertain due to potential contamination of blood culture specimen from skin organisms during sampling. No infections occurred in 248 catheter days in patients alternating TauroLockTM-Hep100 and alcohol 70% with one line change required as CVC moved position. Conclusion CRBSIs pose a serious problem in paediatric HPN patients.1,2 Taurolidine has proven efficacy at preventing CRBSIs and proven superiority to heparin.3 The effectiveness of alcohol at reducing CRBSI rates and preventing CVC replacement has been proven when compared to heparin4 however, due to adverse effects (thrombosis and CVC degradation)4 use is limited to ensure benefits outweigh risks. These studies, although limited, and results in our patient cohort support the continued use of these line locks as per existing practice. Future work includes need to formalise written guideline and discuss clear pathway if patients have multiple CRBSIs on their existing line lock as presently information is unclear. References Koletzko B, Agostoni C, Ball P, et al. ESPEN/ESPGHAN guidelines on paediatric parenteral nutrition. Journal of Paediatric Gastroenterology and Nutrition2005;41:S76–S84. Candusso M, Faraguna D, Sperli D, et al. Outcome and quality of life in paediatric home parenteral nutrition. Current Opinion in Clinical Nutrition and Metabolic Care2005;5:309–14. Chu HP, Brind J, Tomar R, et al. Significant redu[...]



    P11 Extravasation of drugs in children - an analysis of a voluntary incident reporting system

    2018-01-19T07:28:35-08:00

    Aim The aim of this project was to perform an evaluation of the voluntary incident reporting system in place at a tertiary care paediatric hospital, with respect to extravasation injury. This was accomplished by looking at links between events and extravasation risk factors, number of mandatory fields completed within the reports, with respect to hospital guidance and the number of drugs involved in incidents which have a monograph in the local Injectable Medicine Guide with an extravasation risk rating. Method A retrospective review was carried out on anonymised extravasation IR1 reports completed across all medical specialities between 1 st January 2015 and 31 st December 2016. All patients across all medical specialities were eligible for inclusion. A standardised data collection form was used to collect date of incident, time of incident, drug involved and its concentration, area of injury, location of injury, type of access, type of line, treatment given, clinical outcome, level of harm, if aspiration was attempted, if medical staff were informed, was the nurse in charge informed, was the cannula left in situ, was it referred to Plastics, when did Plastics review it and what did they advise and was the area marked out. The Injectable Medicine Guide was used to find the corresponding drug monographs. The data was then analysed using IBM SPSS Statistics 23. Results 347 extravasation incident reports were included in the evaluation, representing 3.05% of IR1s submitted over the study period. 90.2% of injuries involved use of peripheral access and 23.1% of injuries occurred within Paediatric Intensive Care (PICU). The most common location of injury was the hand (33.2%). The top three drugs involved were IV fluids (saline and dextrose), IV fluids (saline, dextrose and potassium) and aciclovir, collectively representing 19.6% of reports. None of the 347 reports contained all eight factors which are required to be documented according to hospital policy. The percentage of each factor completed ranged from 100% for date and type of access, to 10.4% for area of injury. The median number of fields completed was 4, with an interquartile range of 2. 61 out of 347 reports (17.6%) involved drugs which had an explicit extravasation risk rating in the Injectable Medicine Guide (24 different drugs). A further 19 cases had a partial risk rating and involved one further drug not found in the 61 reports. Of the 80 reports with a risk rating, 30 were rated red for at least one risk factor therefore should have been given centrally if possible. 267 reports involved drugs with no extravasation risk rating (27 different drugs). Conclusion Voluntary reports for extravasation injuries are completed, however not all information is being recorded. Factors contributing to this may include formatting of the reporting form, staff attitudes to reporting and lack of knowledge on what to include in the reports. The hospital extravasation group is being reconvened and will be able to prioritise complet[...]



    P12 Factors affecting intravenous fluid bolus administration in paediatrics

    2018-01-19T07:28:35-08:00

    Aim Bolus administration of 0.9% sodium chloride solution has been associated with hyperchloraemia, acidosis, acute kidney injury and increased mortality. Such adverse effects are believed to be less likely with balanced electrolyte solutions, such as Plasma- Lyte 148 or Hartmann’s solution. Despite existing evidence, 0.9% sodium chloride solution remains a popular choice for intravenous fluid boluses in paediatrics. This project aims to establish current practice of fluid bolus administration in paediatric patients, and to collect testimony from prescribers to help understand why decisions to prescribe specific fluids were made. Method Paediatric patients in critical care areas (PICU and PHDU), the Emergency Department (PED) and in general ward areas who had been administered intravenous fluid boluses were identified using a pragmatic data collection technique and the dose, type of fluid, indication and patient’s weight were recorded. Where possible, the prescriber was identified and asked to be interviewed. Prescribers were asked what factors had affected their decision to prescribe the type and dose of fluid administered. Results More than 30 individual episodes of intravenous fluid bolus administration were identified. Most fluid boluses were administered in PICU and PHDU, where balanced electrolyte solutions, specifically Plasma-Lyte 148, were the most popular choice. On general paediatric wards and in PED, 0.9% sodium chloride solution remained the most commonly administered fluid bolus solution. While some prescribers were able to give confident explanations of the factors involved in fluid selection, others referred to clinical guidelines. Individual prescribers described how their prescribing practice would vary according to the clinical setting; with senior clinicians and nursing staff being less accepting of balanced electrolyte solutions in general ward areas. Significant lack of knowledge of intravenous fluid physiology was demonstrated by some prescribers. Conclusion Our findings demonstrate an increase in the administration of balanced electrolyte solutions, such as Plasma-Lyte 148, as fluid boluses; this is in keeping with other international surveys of fluid administration.1,2 Similarly, we have also found significant differences in fluid bolus administration practice across different clinical areas as demonstrated by Jonsson and Perner in 2017. We have demonstrated the importance of on-going multi-disciplinary educational efforts in continuing the evolution of intravenous fluid bolus administration practice to reflect current best practice. References Hammond NE, Taylor C, Finfer S, et al. Patterns of intravenous fluid resuscitation use in adult intensive care patients between 2007 and 2014: An international cross-sectional study. PLoS One2017;12:e0176292. Jonsson AB, Perner A. Changes from 2012 to 2015 in intravenous fluid solutions issued to hospital departments. Acta Anaesthesiol Scand2017;61:532–538. [...]



    P13 Medication use and excipient exposure in paediatrics in a secondary care setting

    2018-01-19T07:28:35-08:00

    Background and aim

    Paediatric patients are widely exposed to a range of excipients which may cause harm to this vulnerable patient group. Legal requirement to disclose quantitative information on excipients changed in 2010,2 however, since most formulations were licensed prior to this date, there is a lack of potentially critical information available to currently practising pharmacists and clinicians. The aim of this study was to quantify excipient exposure to children in a secondary care setting.

    Method

    A cohort study was conducted within Altnagelvin Area Hospital Paediatric Ward (Northern Ireland, Western Health and Social Care Trust) in January 2017. Medicines prescribed to patients throughout the study were recorded and exposure to ethanol, sodium benzoate and propylparaben was quantified.

    Exposure was then compared to proposed safe limits. Off-label and unlicensed use of medicines was assessed as a secondary aim. This study was classified as a service evaluation and ethical approval was not required.

    Results

    A total of 91 patients were enrolled in the study. Patient age ranged from 5 days to 15 years. The mean number of items prescribed per patient was 3.0. Analysis revealed that 75.8% of patients were exposed to ≥1 excipient of interest including ethanol, sodium benzoate and propylparabens. Excipient safety levels as proposed by the European Medicines Agency or World Health Organisation (where available) were not exceeded.

    Quantitative excipient information were not available for two products. There was both off-label and unlicensed use ofmedicines, with off-label prescribing (9.6%) being more common than the use of unlicensed medicines (0.4%).

    Conclusion

    The paediatric population is exposed to potentially harmful excipients contained in commonly prescribed medicines. Although exposure within this study falls within existing safety limits, further research into paediatric specific safe exposure limits are required. It is notable that despite contacting themanufacturer, quantitative excipient information were not available for two products. Safety limits when considered together with quantitative excipient information will allow clinicians to complete an informed risk-benefit analysis for paediatric patients.

    References

  • Tulec C. Paediatric formulations in practice. In Costello I, Long PF, Wong IK, Tulec C, Yeung V (Ed.), Paediatric drug handling 2007:pp. 43–74. London: Pharmaceutical Press.

  • European Commission. A guideline on summary of product characteristics [Online]2009;2:1–29. http://ec.europa.eu/health//sites/health/files/files/eudralex/vol-2/c/smpc_guideline_rev2_en.pdf [Accessed: 14th April 2017].




  • P14 Pioneering use of brincidorfovir to treat adenovirus infection in a paediatric patient post bone marrow transplant

    2018-01-19T07:28:35-08:00

    Background Brincidofovir (BCV) is an antiviral drug currently undergoing stage 2 clinical trials in America. BCV is released only on direct application with subsequent approval from the manufacturer; Chimerix. It is currently available via the Named Patient Program (NPP); an open-label, non-randomised, multi- centre expanded access program that provides access to BCV for patients that are not currently enrolled in a BCV clinical trial. It has previously been approved for use in Adenovirus treatment, with requests for use in other indications being denied. On day +33 post bone marrow transplant (BMT), our patient began suffering from gut graft versus host disease (GVHD). According to Trust protocol, he was started on methylprednisolone intravenously(IV), then budesonide orally (PO). He received subsequent courses of infliximab(IV), basiliximab (IV), and ruxolitinib (PO). During treatment with ruxolitinib the patient was diagnosed with Adenovirus. This is not routinely treated in otherwise well patients, however due to severe immunosuppression following BMT and high dose steroids for GVHD, cidofovir was started. No improvement was seen, and viral load continued to increase (from 7290 copies/mL on day +74 to 9 53 000 copies on D+83) alongside cidofovir related renal toxicity. Pharmacist contributions After a discussion with the MDT since BCV is experimental and unlicensed, the specialist pharmacist (SP) contacted Chimerix to begin the application process alongside the Lead Consultant; providing detailed clinical information for panel approval. The Chief Pharmacist was contacted to ensure correct paperwork was in place, ensuring import of an unlicensed medication from America would be both financially sound and approved for use within the Trust. The SP then contacted the Trust pharmacy purchasing department and created a new line form on the Trust’s dispensing programme ready to receive the product; shipping and delivery arrangements were organised with the company. Finally the SP contacted the pharmacy Quality Assurance/Quality Control department to agree any further verification before use in a patient at the Trust. Treatment began at 2 mg/kg twice weekly on day +90 post transplant. The SP explained the key information in the pharmacy manual and individualised treatment plan for the patient to the MDT, and ensured the product did not interact with current BMT regimen. A major side effect identified during clinical trials was diarrhoea, which due to pre-existing GVHD was difficult to distinguish so the patient was closely monitored with regular stool charts and fluid balance review. Outcome The patient significantly improved, with adenovirus load becoming undetectable (<50 copies/mL) after 9 doses of BCV. Two negative blood polymerase chain reaction (PCR) results were received before stopping treatment on day +119. Lessons learned BCV has been shown to be a useful agent to use to treat [...]



    P15 Eculizumab treatment for a paediatric stem cell transplant (sct) patient diagnosed with transplant-associated thrombotic microangiopathy (tma)

    2018-01-19T07:28:35-08:00

    Background TMA is a life threatening complication with a high mortality rate in SCT patients.1 The pathophysiology involves damage of the endothelial lining via over activation of the complement system which forms part of the innate immune system.2 Complications include; kidney damage, pulmonary hypertension and possible multi organ failure.1 Eculizumab is an agent that exhibits activity by inhibiting the complement system however dosing and effects in the paediatric population are lacking.1,2 An 18 year old patient was admitted to the paediatric SCT unit for a sibling haploidentical SCT. On day +48 she developed worsening acute kidney injury, hypertension and confusion. She was diagnosed with TMA confirmed via fragments on the blood film, blood in the urinalysis and an elevated lactate dehydrogenase (LDH). Summary of the problem encountered The use of eculizumab is limited in paediatric centres. Furthermore there is limited dosing and monitoring information available for paediatric patients for the unlicensed indication of TMA. The urgent nature of the request of this medication due to the rapid deterioration of the patient meant there was no time to submit a non- formulary drug application or develop local protocol guidance. However when presented with a drug request for an unfamiliar drug several # had to be taken to ensure the safe and effective use of this drug. Pharmacy contributions The first step involved determining an appropriate dosing regimen. A literature search was conducted alongside the attending consultant to determine this. Consequently the pharmaceutical company was contacted requesting a supply of the drug and required paperwork completed including a certificate of vaccination form. The next step involved calculating the total anticipated treatment cost as eculizumab is an extremely expensive drug. As this was non formulary and off label, the attending consultant took clinical responsibility and approval was sought from the Chief of Service and Chief Pharmacist. A prescription and administration proforma was designed which also included monitoring information and pre-medication required. Monitoring parameters to determine clinical efficacy were closely observed, this mainly included LDH and CH50 levels. Outcome The patient clinically improved and eculizumab was stopped on day +222, the treatment course was longer than originally anticipated however CH50 levels were suppressed to <25%. Lessons learned Although unlicensed eculizumab was effective against TMA complications experienced post SCT. This is however a high cost drug with complex monitoring requirements, also requiring a vast amount of support from pharmacy services. Procedures are underway to develop local guidance for its use and also individual funding requests to be completed before treatment in order to gain funding for individual cases for this off label condition. References J[...]



    P16 Pharmacist prescribing in neonatal intensive care units in the uk: an update

    2018-01-19T07:28:35-08:00

    Aim Following the amendment of the Misuse of Drugs Act in 2012,1 pharmacists have the same prescribing rights as medical prescribers. A survey in 20122 looked at how far this had been implemented in Neonatal Intensive Care Units (NICU) in the UK. This follow up survey looked at how much progress has been made in the past five years. Method Neonatal and Paediatric Pharmacist Group (NPPG) members working in NICU were invited to complete an electronic survey to determine the extent of prescribing being undertaken and what, if any, barriers were encountered for this service development. Results 40 responses were received, with the majority (23) working in Level 3 units. Just over half (56%) were prescribers, with 53% being independent prescribers. This compares with 47% and 40% in 2012. Of those not currently qualified only 8% had no plans to undertake the course (27% in 2012). The areas where pharmacists were prescribing were similar to 2012 with 70% prescribing in NICU or Special Care Baby Units (SCBU). As in 2012, 19% of those qualified were not prescribing. The majority of respondents were sole pharmacists on their units (54%), with 34% having two pharmacists and one unit had 4 pharmacists (all prescribers) Main medicines being prescribed were nutritional supplements (86%), Parenteral Nutrition (76%), antibiotics (76%), caffeine (67%) and reflux medication (62%). More pharmacists were prescribing controlled drugs (50%) and clinical trials medicines (12%), up from 5% and 2.5% respectively in 2012. Improvement in safety was seen as a benefit of pharmacist prescribing, with quicker access to medicines for patients. Freeing up medical staff time, allowing teams to focus on diagnosis and stabilising sick babies, was also seen as a benefit. Pharmacist prescribers can demonstrate good prescribing practices and set an example for other prescribers, particularly junior medical staff and trainee Advanced Neonatal Nurse Practitioners (ANNP) Pharmacists were generally seen as the most consistent presence on the unit and so are more aware of medication histories of patients, facilitating better discharge planning and communication with families regarding items such as unlicensed specials and prescribable feeds. Pharmacist’s knowledge of medicine formulations meant that they were more likely to consider if doses are measurable when prescribing It was also felt that being a prescriber helped the pharmacist to integrate more into the multidisciplinary team. Few barriers were reported, with medical and nursing staff supporting the process. The main barriers were pharmacy related: funding being prioritised to adult services and the need for a second pharmacist to clinically check the prescribing were reported. Conclusion Pharmacist prescribing has developed since the previous survey in 2012 with the process now embedded as routine practice in many un[...]



    P17 Pharmco-stability of plasma-lyte 148 and plasma-lyte 148% glucose 5% with frequently used infused therapeutic agents

    2018-01-19T07:28:35-08:00

    Aims

    Plasma-Lyte148 is a balanced, crystalloid fluid which has been shown to circumvent the hyperchloraemic metabolicacidosis associated with 0.9% Saline. There is limited compatibility data available to support the co-administration of this fluid with commonly infused medications. Such data is essential to support the safe introduction of this fluid, especially in children where intravenous access is often limited. This study aimed to expandon knowledge in this area by assessing the chemical and physical compatibility of Plasma-Lyte with a range of medicines.

    Methods

    Adrenaline, Dobutamine, Dopamine, Furosemide, Midazolam, Milrinone and Morphine were mixed with Plasma-Lyte, Plasma-Lyte with 5% Glucose, and the two control solutions 0.9% Saline and 5% Glucose. Chemical compatibility was assessed by High Performance Liquid Chromatography using the Thermo Scientific UltiMate 3000 system. Physical compatibility was assessed by checking for colour changes and precipitate formation. pH of the admixtures was recorded using a Fisherbrand Hydrus 3000 pH metre. 6 repeats were carried out for HPLC and 2 for physical compatibility checks and pH measurements, with all admixtures assayed at 0, 2 and 24 hours. Chemical stability was defined as <5% change in concentration and pH was considered acceptable for peripheral administration if it was between 5 and 9 at all time points.

    Results

    Adrenaline, Dobutamine, Dopamine, Morphine and Milrinone were chemically and physically stable when diluted with Plasma-Lyte 148 and Plasma-Lyte 148 with 5% Glucose. Furosemide was compatible with Plasma-Lyte 148, but not Plasma-Lyte 148 with 5% glucose. Midazolam was not compatible with Plasma-Lyte 148 or Plasma-Lyte 148%–5% glucose at the tested concentration of 3 mg/mL. Only Dobutamine, Dopamine, Furosemide and Morphine remained within the pH range 5–9 when mixed with Plasma-Lyte 148 and Plasma-Lyte 148 with glucose.

    Conclusion

    Adrenaline, Dobutamine, Dopamine, Morphine and Milrinone can be mixed with Plasma-Lyte 148 and Plasma-Lyte 148 with glucose in clinical practice. Furosemide can beco-administered with Plasma-Lyte 148, but not Plasma-Lyte 148 with 5% glucose. Midazolam should not be mixed with Plasma-Lyte 148 and Plasma-Lyte 148 with glucose at a concentration of 3 mg/mL.




    P18 Plasma-lyte 148 vs 0.9% saline for fluid resuscition in children: electrolytic and clinical outcomes

    2018-01-19T07:28:35-08:00

    Aims Crystalloid fluid boluses are a mainstay of treatment in unwell children, with the traditional fluid of choice being 0.9% saline (NS). However, the use of NS has been associated with an increase in plasma chloride levels and acidosis, leading to kidney injury and other detrimental clinical effects. Plasma-Lyte 148 (PLA) is a balanced, physiological, crystalloid intravenous fluid, which is both calcium-free and isotonic. Its use in place of NS for fluid resuscitation may circumvent hyperchloraemic metabolic acidosis. In May 2015 our hospital altered its standard resuscitation fluid from NS to PLA. We aimed to compare the effect of fluid boluses of NS to those of PLA in children. Methods All patients admitted in the 18 month periods before and after the change from NS to PLA, and receiving a fluid bolus in the first 24 hours of admission, were included. Post-surgical patients and those who had undergone haemofiltration were excluded. Arterial blood gas and creatinine values for up to 5 days after bolus fluid administration were examined. Patients were stratified according to the total resuscitation volume (ml/kg), then split into categories determined by the balance of PLA vs. NS. The primary outcome was plasma chloride. Secondary outcomes included blood pH and percentage change in creatinine. Clinical outcomes were length of ventilation and length of PICU stay. Results 126 patients were included in the analysis. Patients receiving NS boluses tended to have a higher maximum chloride, higher average chloride, lower pH and higher percentage creatinine increase than those given PLA. Subgroup analysis showed a statistically significant difference in average serum chloride for the 61–90 ml/kg group {PLA 105.59±1.29 vs NS 111.29±2.1 mmol/L; difference: –6.21 [95% confidence interval (CI)–9.55,–2.87]}. Patients who received PLA tended to have a higher pH than those receiving NS. A statistically significant difference was seen in the 10–30 ml/kg group [PLA 7.42±0.49 vs NS 7.33±0.65; difference: 0.0913 (95% CI: –0.18 to –0.02)]. Significant differences were not seen in the clinical outcomes of length of stay or ventilation Conclusion PLA as a resuscitation fluid is significantly associated with a more physiological plasma chloride and pH across several resuscitation fluid volume categories, when compared to NS. The trends in the other fluid volume categories are in line with these findings, but are not statistically significant. There was also a trend towards patients receiving PLA having a lower percentage rise in creatinine than those who received saline. These results were consistent over all weight and age categories. [...]



    SP3 The effect of electronic prescribing and medicines administration systems (epmass) on paediatric medication errors

    2018-01-19T07:28:35-08:00

    Background The complex nature of paediatric prescribing makes this population more vulnerable to medication errors.1Electronic Prescribing and Medicines Administration Systems (EPMASs) have been suggested to improve paediatric medication safety by reducing prescribing errors. Aim To identify and compare the number and nature of paediatric medication errors pre and post introduction of an EPMAS at a tertiary paediatric hospital. Methodology Pharmacists collected data monthly on the number of new items prescribed and the number of errors (if any) detected in these prescriptions following methodology from the EQUIP study.2 The EPMAS Meditechv6 was introduced in June 2015. Data analysed included forms from 1st-January-2015 to 30th-June-2015 (period 1: pre-EPMAS) and 1st-January-2016 to 30th-June-2016 (period 2: post-EPMAS). The analysis aimed to investigate the rate, type and severity of errors as well as the prescriber grade, prescribing stage and drug class associated with each. Descriptive statistical methods were used to analyse the frequency and nature of errors pre and post implementation of Meditech. Statistical significance was tested using a contingency Chi-squared (2) test for the difference in error rates across both periods and a Mann-Whitney test for the difference between the severities of errors across both periods Results An increase of 6.4% in error rate was detected post-Meditech introduction with 67 errors in 1706 items (3.9%) during period 1 and 151 errors in 1459 items (10.3%) during period 2 (p<0.001, 2 test). FY2 doctors and ‘admission stage’ were associated with the highest error rates across both periods. Minor severity errors were the most common in both periods, with 55.2% in period 1% and 66.2% in period 2. No statistical difference was detected (p=0.403) in the severity of errors reported although the proportion of significant and serious errors decreased from 38.8% to 27.8% and 6.0% to 0.7% respectively. No errors were classed to be potentially lethal in period 1, however there was one such incident in period 2. Underdosing was the most common error type in period 1 (22.4%), falling to 4.0% in period 2. Omission on admission was the most common error type in period 2, with an error rate of 37.7% vs 20.9% in period 1. Antibacterials and analgesics were the most common classes of drugs involved in errors in both periods, although a wider range of drug classes were involved in errors post Meditech introduction Conclusion A significant increase of 6.4% in error rate was found post implementation of Meditech highlighting the concept of EPMAS-facilitated errors. The positive effect of EPMASs is also apparent as the incidence of significant and serious errors decreased in period 2, although this difference was not statistic[...]



    P19 Clinical pearl: pharmaceutical management of siblings with guanidinoacetate methyltransferase (gamt) deficiency

    2018-01-19T07:28:35-08:00

    Situation Patient A and B are 9 and 4 year old siblings with developmental delay and in particular; speech delay, seizures and behavioural difficulties. They were found to have GAMT deficiency due to a heterozygous pathogenic GAMT splicing mutation c.327G>A and pathogenic GAMT nonsense mutation c.522G>A (Trp174Ter). Patient A and B were referred to the regional metabolic team for further input. Management of this rare disorder involves combination treatment with specialist medications and a protein restricted diet.1,2 Background GAMT deficiency is an inherited disorder of creatine synthesis.1,2 Approximately 110 patients have been diagnosed world wide.1 Main clinical features are intellectual disability with speech and language delay, behavioural problems and epilepsy.1,2 Creatine is an important energy source formuscle and brain. The enzyme arginine: amidinotransferase (AGAT) synthesises guanidinoacetate (GAA) using arginine and glycineas substrates.1,2 The enzyme GAMT in the liver then catalyses the last step of creatine synthesis converting GAA into creatine.1,2 Creatine is transported via the bloodstream to other organs where it is utilised.1 In GAMT deficiency there is a deficiency of creatine and an excess of GAA causing neurotoxicity. The sibling’s history and presentation were consistent with GAMT deficiency and plasma GAA levels done before starting ornithine were very elevated confirming the genetic finding. Treatment Creatine supplementation restores deficient levels. L-Ornithine competitively inhibits the enzyme AGAT reducing GAA synthesis. An arginine restricted diet and sodium benzoate deprives the pathway of arginine and glycine respectively reducing GAA synthesis.1,2 Outcome 6 months after starting treatment with creatine (400 mg/kg/day) and l-ornithine (400 mg/kg/day), a significant clinical improvement has been observed. Patient A has had improvement in memory recall, speech and sleeping, and her seizures have reduced from daily to occasionally. Her plasma GAA levels have decreased from 13.3 to 6.5 micromoles/L (0.8–3.1 micromole/L). A bigger improvement has been seen for patient B, probably explained by an earlier age of intervention. Seizures have stopped, with normalisation of his electroencephalogram. His behaviour, attention span and speech have improved, with an ability to form sentences and a widening vocabulary. He is able to walk up the stairs rather than crawl or bottom-shuffle. His plasma GAA has decreased from 14.7 to 8.0 micromoles/L. Doses of l-ornithine and creatine have been increased further to 600 mg/kg/day. Both have had brain magnetic resonance spectroscopy on treatment showing there is no creatine deficiency. Lessons learnt Management of GAMT deficiency requires multidis[...]



    P20 Stability study of a mixed system of sodium benzoate and sodium phenylbutyrate in intravenous (iv) infusion fluids

    2018-01-19T07:28:35-08:00

    Aim A combination of sodium benzoate and sodium phenylbutyrate is used as intravenous therapy in hyperammonaemia at concentrations up to 50 mg/mL. Currently, concentrated solutions of each component are available. The preparation relies on the accurate measurement of each component in a syringe or bag which then mixes via a Y-site, immediately prior to administration. A ready mixed product would potentially confer improvements in safety and convenience. An improvement would be the availability of a pre-mixed product, which requires less manipulation prior to administration. The aim of this work was to evaluate the chemical stability of a mixed system of sodiumbenzoate and sodium phenylbutyrate in glucose 10%, with relevant packaging conditions both at room temperature and at accelerated- degradations temperatures, with exposure to ultra violet (UV) light. Successful demonstration of compatibility across a range of conditions may provide impetus for the manufacture of pre-mixed intravenous therapy. This would improve efficiency of intravenous drug preparation and administration with the associated patient safety benefits of more accurate drug concentrations. Method The chemical stability of sodium benzoate and sodium phenylbutyrate was monitored by measuring concentrations using high-performance liquid chromatography. The stability of the mixed system was evaluated at a range of concentrations(20 mg/mL, 25 mg/mL, 30 mg/mL, 40 mg/mL and 50 mg/mL) of both components in solutions of 10% w/v glucose in deionised water stored at three temperatures; refrigerated (4°C–8°C), at room temperature (20°C–25°C), and at 37°C. Glass and plastic were compared as packaging materials both with and without exposure to UV light. All mixed solutions were stored for up to 12 weeks. Results Drug content remained above 98% for all mixed systems at all conditions for 12 weeks. Conclusion Combination mixed systems of sodium benzoate and sodium phenylbutyrate were found to be stable for up to 12 weeks when stored in glass or plastic containers, exposure to high temperatures and UV light did not significantly affect the concentration of the drug present. This stability data will allow institutions to prepare pre-mixed solutions in advance for sodium benzoate and sodium phenylbutyrate in 10% glucose.It has patient safety benefits as it provides support of current clinical practice of the IV drug compatibility of sodium benzoate and sodium phenylbutyrate. It also provides quantitative reassurance in larger patients where current practice is to add the two drugs to a single bag for infusion. Moreover, it may also pave the way for commercial manufactured solutions of sodium benzoate and sodium phenylbutyr[...]



    P21 Prescribing lvacaftor in paediatric patients with cystic fibrosis (cf) in accordance with the clinical commissioning policy in an nhs trust

    2018-01-19T07:28:35-08:00

    Introduction CF is a genetic condition affecting more than 10 800 people in the UK. CF is caused by a mutation in the gene cystic fibrosis trans membrane conductance regulator (CFTR).Prior to the licensing of Ivacaftor, standard treatment for CF was to treat symptoms associated with CF but not the underlying cause. Ivacaftor targets the CFTR gene. Ivacaftor is funded by NHS England, if criteria outlined in the clinical commissioning policy is followed.1,2 Aim Ensure Ivacaftor is prescribed in adherence to guidance documented in the Clinical Commissioning Policy: Ivacaftor for CF (2012) and Clinical Commissioning Policy: Ivacaftor for children aged 2–5 years with CF, named mutations (2016).1,2 Standards 100% of Ivacaftor prescriptions will be for patients: 2 years of age or older Have a G55ID mutation 100% of patients will receive lung function test (6 years and older) and baseline sweat test 6 months prior to commencing treatment 100% of patients will receive a follow up sweat test/lung function test (6 years and older) at: Next routine appointment 6 months after starting treatment Annually thereafter 100% of patients who don’t attain an adequate treatment response will discontinue Ivacaftor Method Retrospective study investigated the prescribing of Ivacaftor in CF patients from March 2012 – June 2017 at an NHS trust. Ethics approval not required. List of patients prescribed Ivacaftor was obtained from the CF team. Patient age, mutation type, treatment start dates, lung function test results were obtained from medical notes. Dates and results of sweat tests were obtained from Sunquest ICE Desktop (electronic patient reporting system). Data analysed using Microsoft excel. Results Eight patients prescribed Ivacaftor at the NHS trust between March 2012–June 2017. Baseline sweat chloride data unavailable for one patient who was previously part of a clinical trial. This patient was excluded from standard 2, however maintained for the other standards as his annual sweat data was available. One patient was excluded from standard 3(a), five patients excluded from standard 3 (b), (c) as they had not yet reached this stage of treatment. Standard 4 was not evaluated as all patients to date were responding to treatment. Overall, all standards were completely met with a result of 100%. Discussion and conclusion Standards were completely met; highlighting a robust system ensuring all appropriate testing is adhered to, as failure to comply with the criteria in the clinical commissioning policy may contribute to pressure within the trust’s budget. Treatment response can also be appropriately determined. Recommendations Ensure data is inputted onto the[...]



    P22 Reducing the time that short stay surgical patients wait for discharge medication

    2018-01-19T07:28:35-08:00

    Aim To reduce the amount of time that short stay surgical patients wait for their discharge medication. Method An audit was carried out during 1 week in September 2016 of all discharge prescriptions written on the paediatric surgical ward. It measured time taken for the prescription to be processed by pharmacy and the number of prescriptions for paracetamol and ibuprofen. An intervention was introduced in February 2017: Parents/carers of children coming in for elective surgery were instructed (as part of their pre-admission letter) to buy paracetamol and ibuprofen. Nursing staff also reminded parents/carers when the child was admitted, that they would need to have these medicines on discharge. When a discharge letter was written, patients were not given paracetamol and ibuprofen. They were given a dosing instruction letter completed by the pharmacist at point of clinical check. Provision was made to supply the medication if a parent/carer could not provide it. The letter and dosing were designed by a paediatric pharmacist in conjunction with a paediatric anaesthetist to ensure patients were discharged on optimal pain control.1 A re-audit was carried out over the course of 1 week in June 2017. Results In September 2016, a total of 37 prescriptions were written from the paediatric surgery ward over a 1 week period. The average (mean) time to dispense a prescription was 76 min (range 16–200 min). In June 2017, a total of 30 prescriptions were written over a 1 week period. The average (mean) time to dispense a prescription was 51 min (range 10–124 min). There was a reduction in the mean waiting time of 25 min but this did not reach statistical significance (p=0.3). In September 2016, 12 prescriptions (32%) were for elective patients for paracetamol and ibuprofen only. Average time to dispense these prescriptions was 70 min. In June 2017, 7 prescriptions (23%) were for elective patients for paracetamol and ibuprofen only and an instruction letter was issued on the ward. Average time to complete these prescriptions was 21 min. There was a reduction in the mean waiting time of 49 min which was statistically significant (p=0.001). Time was measured from the time the pharmacist was informed the prescription was ready, to the time the medication or letter was ready and on the ward. Conclusion Introduction of an instruction letter given to elective surgical patients on discharge appeared to lead to a shorter wait for discharge medication, although this was not statistically significant. A significant reduction in waiting time was seen for patients who were only prescribed paracetamol and ibuprofen and could be discharged without their prescription le[...]



    1 Developing consensus on hospital prescribing indicators of potential harm for infants and children

    2018-01-19T07:28:35-08:00

    Aims To develop a list of hospital based paediatric prescribing indicators that can be used to assess the impact of electronic prescribing or clinical decision support tools on paediatric prescribing errors. Background Medication errors are a major cause for concern in the NHS. Prescribing is part of the medication use process and is a complex task requiring an understanding of medicines, disease processes, and patient parameters. Systematic reviews have reported that medication errors occur in as many as 50% of hospital admissions and prescribing error rates in the UK hospitals vary between 9% and 15%. Prescribing for children is further complicated by the need to take into account weight, altered physiology and pharmacokinetics. Prescribing error rates of 13.1% have been reported in children with a potentially greater impact due to the nature of the patients. Electronic prescribing (EP) while relatively uncommon in UK hospitals is an important tool in reducing prescribing errors. EP systems have been shown to have a positive impact on prescribing errors, however methodologies vary and the reduction in harm is rarely investigated. A standard tool to allow an evaluation of the harm reduction is desirable and currently does not exist for the paediatric setting. Methods Two rounds of an electronic consensus method (eDelphi) were carried out with 21 expert panellists from the UK. Panellists were asked to score each prescribing indicator for its likelihood of occurrence and severity of outcome should the error occur. The scores were combined to produce a risk score and a median score for each indicator calculated. The degree of consensus between panellists was defined as the proportion that gave a risk score in the same category as the median. Indicators were included if a consensus of 80% or higher was achieved and were in the high risk categories. Results An expert panel consisting of 8 pharmacists and 13 paediatricians with a total of 437 years of clinical experience completed an exploratory round and two rounds of scoring. This identified 41 paediatric prescribing indicators with a high risk rating and greater than 80% consensus. The most common error type within the indicators was wrong dose (n=19) and the most common drug classes were antimicrobials (n=10) and cardiovascular (n=7). Conclusions A set of 41 paediatric prescribing indicators describing potential harm for the hospital setting have been identified by an expert panel. The indicators provide a standardised method of evaluation of prescribing data on both paper and electronic systems. They can also be used to assess implementation of clinical decision support sys[...]



    P1 The potential for pharmacists to manage young patients attending emergency departments

    2018-01-19T07:28:35-08:00

    Background There have been concerns about maintaining appropriate clinical staff levels in Emergency Departments in England.1 One possible solution to alleviating the workforce pressure is the extension of clinical activity performed by non-medical staff – including pharmacists.2 Aims and objectives To determine if Emergency Department attendees aged from 10–25 years (adolescents) could be clinically managed by community pharmacists or hospital pharmacist independent prescribers with or without further advanced clinical practice training. Method A prospective 49 site cross-sectional observational study of patients attending Emergency Departments (ED) in England, UK. Each site was requested to collect data for 400 admissions of all ages. Pharmacist independent prescribers (one for each site) were asked to identify patient attendance at their Emergency Department, record anonymised details of the cases – age, weight, presenting complain, clinical grouping (e.g. medicine, orthopaedics) and categorise each one into one of four possible categories: CP, Community Pharmacist, cases which could be managed by a community pharmacist outside an ED setting; IP – cases that could be managed in ED by a hospital pharmacist with independent prescriber status; IPT, Independent Prescriber Pharmacist with additional training – cases which could be managed in ED by a hospital pharmacist independent prescriber with additional clinical training; and MT, Medical Team only – cases that were unsuitable for the pharmacist to manage. An Impact Index was calculated for the two most frequent clinical groupings using the formula: Impact index (I)=proportion of the total workload of the clinical grouping (w) multiplied by the percentage ability of pharmacists to manage that clinical group (a). I=wa. The higher the Impact Index the greater potential for pharmacists to support the clinical workload related to that group. Results 2993 out of 18 613 (16%) attendees were young patients aged from 10 to 25 years of age (median 20 years, interquartile range 17–22 years) of which 1530 were female and 1463 were male. Of the 2993 patients, 6% of the cases were judge to be suitable for the community pharmacist (CP), 5% suitable for a hospital pharmacist independent prescriber (IP), 37% were deemed as suitable for a hospital independent prescriber with additional training (IPT) and the remaining 52% were only suitable for the medical team (MT). The most frequent clinical groups and Impact Index were general medicine=16.97 and orthopaedics=15.51. Conclusion Emergency Department attendees who were [...]



    P25 Can electronic prescribing facilitate safe and measurable dose administration in children?

    2018-01-19T07:28:36-08:00

    Aim A previous study identified that prescribed doses of liquid medicines could not always be measured using a single syringe.1 Our study aimed to identify whether electronic prescribing improves this and if so how different the prescribed dose would be compared to the BNFC/local dosage recommendations. Method Liquid and parenteral medicine prescriptions prescribed using paper drug charts, with doses calculated manually, were reviewed on neonatal and paediatric wards during 2 days in July 2014. Electronic prescribing (Epic) was introduced in October 2014 with study observations repeated in April 2016. Patient weight, dose, strength and volume administered were recorded, with analysis of whether doses could be measured using a single syringe. Prescribed doses were compared with the exact calculated BNFC/local dose. Results 381 liquid medicine doses were reviewed pre-electronic prescribing, and included 75 formulations. 99 (26%) doses were immeasurable. Of these, 42 (42.4%) doses would have been administered with less than 1% difference to the prescribed dose, 31 (31.3%) between 1%–2% difference and 26 (26.2%) between 2%–10% difference. 134 (35.2%) doses were calculated and prescribed exactly using BNFC/local recommendations. 139 (36.5%) doses were adjusted and prescribed with less than 2% difference to the exact calculated dose, 70 (18.4%) between 2%–5% difference and 38 (10%) with >5% difference. 365 liquid medicine doses were reviewed following electronic prescribing implementation, and included 105 formulations. 80 (21.9%) doses were immeasurable. Of these, 35 (43.8%) doses would have been administered with less than a 1% difference to the prescribed dose, 16 (20%) between 1%–2% difference and 29 (36.3%) between 2%–10% difference. Following introduction of electronic prescribing 166 (45.5%) doses were calculated and prescribed exactly using BNFC/local recommendations. 140 (38.3%) doses were adjusted and prescribed with less than 2% difference to the exact calculated dose, 34 (9.3%) between 2%–5% difference and 25 (6.8%) with >5% difference. Conclusion There was a small improvement in numbers of measurable doses prescribed using electronic prescribing, with an improvement in the final calculation of prescribed doses compared with BNFC/local doses. Although more doses were measurable using electronic prescribing, there was also an increase in the number of doses with >2% difference between the prescribed and administered dose. The World Health Organisation provide guidance on dose rounding and if prescribed doses do not corres[...]



    P26 A journey to improve the safety of iv paracetamol prescribing and administration in neonates and small children

    2018-01-19T07:28:36-08:00

    Aim Since September 2014, BNFC has suggested an intravenous paracetamol (IV-P) dosing regimen for children under 10 kilograms which has on occasions been misinterpreted resulting in total daily dose >30 mg/kg being prescribed and administered. Reported errors with IV-P include accidental overdose in children associated with the large vial size, 10-fold drug calculation errors, confusion between the dose volume in millilitres and milligrams and errors when setting up infusion pumps to administer a dose.1–3 Furthermore, in 2006 the NPSA raised an alert which created concern with the risk of inadvertent overdose of IV-P in children, citing over 200 incidents including two associated with severe harm.4 The aim was to decrease the rate of medication incidents involving IV-P prescribing and administration in neonates and small children. Method In 2015 we introduced a number of measures to target prescribing and administration errors in the hospital. These included: May2015: Clarification by the drug and therapeutics committee of the dose of IVparacetamol to be used in RBHSC for term neonates and children weighing under10 kilograms to be ‘7.5 mg/kg every 6 hours, maximum 30 mg/kg/day’ – Adeparture from the regimen suggested by BNFC. July2015: Procurement of lower dose IV–P preparations, 40 mg and 100 mg, for use inchildren weighing less than 5 and 10 kilograms respectively. August 2015: Development and circulation of a ready reckoner to guide the correctprescribing, preparation and administration of IV–P doses to term neonates andchildren. Results Datix reports of medication incidents involving IV-P were collated from January 2014 – June 2016. In the preceding 17 month period before the interventions the average IV-P reporting rate was 0.94 incidents per month. In the initial 9 month period following the introduction of the above measures, reported medication incidents involving IV-P were reduced to zero, however this effect started to diminish from month 10 onwards (March 2016). The average incident reporting rate for the 9 month post-intervention period was 0.38 incidents per month. Conclusion The measures introduced were initially effective in reducing the rate of medication errors involving IV-P however the efficacy diminished after a period of approximately 9 months. This period coincided with medical staff changeover however this may be an incidental finding. Clear benefits to the safety of IV-P prescribing and administration have been demonstrated however strategies to provide sustainability of[...]



    P27 Introduction of oral caffeine rounds on the neonatal units

    2018-01-19T07:28:36-08:00

    Aim Apnoea of prematurity is common in babies born at less than 34 weeks gestation due to immature respiratory control systems.1–4 The current mainstay of treatment in the UK is a methylxanthine – caffeine – which acts as a respiratory stimulant. Our local guideline follows the Caffeine for Apnea of Prematurity (CAP) study with a single loading dose followed by 24-hourly maintenance doses, given either intravenously or orally1. In August 2012 a UK licenced oral caffeine product was launched, however various safety concerns were raised over this product and its presentation which led to delays in use on our Neonatal Units (NNUs). Unfortunately the single patient, single use product would also lead to a massive increase in our oral caffeine spend – with the cost of an average dose of oral caffeine rising from just £0.13 to £24.41. This equates to an annual cost increase of approximately £53,140 – around a 150-fold increase from the previous £360 per annum. We have therefore considered and implemented a new initiative to avoid unacceptable cost pressures within the neonatal service. Methods Consideration was made to administering caffeine doses in ‘rounds’ on NNU to allow doses for more than one patient from a single bottle. However, there were a number of issues to overcome – the oral caffeine rounds would require the product to be used outside of its licence. We also needed to be sure that limiting the timing of caffeine administration to standard times on the NNUs – provisionally twice daily rounds at 10:00 and 22:00 – would not affect its therapeutic and potentially toxic effects in this vulnerable patient group. Savings as a result of this initiative were to be tracked for one year post implementation. Results Total savings in the first 10 months following implementation were £15,945 – a projected saving of £19 134 per annum. There have been no reports of any adverse clinical outcomes related to timing of caffeine doses. Conclusion Given the success of this initiative we plan to move towards a once daily oral caffeine round on our NNUs at 10:00. The majority of babies currently receive their dose at this time but formal implementation will lead to further cost savings. A morning oral caffeine round will also help to minimise the at least theoretical risk of the CNS stimulant effects and cardiac effects of caffeine, principally tachycardia, disrupting a baby’s sleep pattern. There is some evidence of this in t[...]



    P28 Implementation of clinical pharmacy services at weekends within a tertiary childrens hospital

    2018-01-19T07:28:36-08:00

    Aim The need to improve the provision of Pharmacy services across seven days was highlighted in the initial findings of a report commissioned by the Medical Director of NHS England.1 The authors commented that Pharmacy services should be regarded as a priority in the first stages of transformational project work. The aim of this study was to evaluate the impact of specialist paediatric pharmacists working directly within the children’s wards of a tertiary paediatric centre within a large teaching hospital at weekends. Method Clinical pharmacists within our organisation have not routinely provided ward based services at weekends. Pharmacists were based within the inpatient dispensary or aseptic preparative service managing supply requests for medicines from a range of adult and paediatric specialities. Information queries were managed by the dispensary teams, or referred to the duty Medicines Information pharmacist. Changes were made to the weekend service specification to ensure a paediatric specialist pharmacist was available to provide ward based clinical pharmacy service to paediatric areas at the weekend. Requests for medicines for children’s areas were referred to a specialist paediatric pharmacist. The service specification included requests for supply of non-stock medicines, medicines for discharge and orders for aseptically prepared items. All orders for medicines supply were managed within the ward environment. The pharmacist was available to patients and carers, had access to medical and nursing teams, patient information and could assess patients own drugs for discharge. The duty paediatric pharmacist was available to answer clinical pharmacy related enquiries from ward staff. Details of complex patients who may need weekend review were transferred from weekday teams to the weekend duty pharmacist. Records were kept of the weekend workload Results A median of 7 clinical queries per weekend were managed by the weekend paediatric pharmacist. On average, 20 patients per weekend required discharge prescription management, including clinical validation, patient counselling and assessment of patients own medicines suitable for use on discharge. Twelve requests for non-stock medicines were made on a typical weekend. Staff feedback was sought following the initiation of the new weekend service. Pharmacists reported increased satisfaction in the service they provided and felt it was a more appropriate use of their skill set. Details of enquiries from children’s wards were[...]



    P29 Impact of a medicines facilitation pharmacist on a paediatric ward

    2018-01-19T07:28:36-08:00

    Aim Recruiting sufficient numbers of nurses can provide a challenge for hospitals. Pharmacists have been identified as being able to support nurses by taking on medicines management tasks alongside traditional nursing responsibilities such as medicines administration and discharge planning.1 At Barts Health NHS Trust there was increased pressure on nursing staff particularly on one of the complex medical wards during the winter pressure months. Paediatric pharmacists were identified as being able to support nurse: Safe nursing time by taking on some of nursing responsibilities Active discharge planning and coordination Reduce discharge prescription waiting times Improve education and training for nurses, doctors and patients in relation to medicines management. Method A pilot project on one paediatric medical ward was started in February 2016. The pharmacist is supernumerary to standard ward pharmacy service, reporting to the ward manager and lead pharmacist. Working hours are 9 am–5 pm Monday to Friday. Intensive training was provided over 2.5 weeks with subsequent sign off for administration of oral medication, 2nd checking for intravenous (IV) medication and IV giving. Drug listing for discharge prescription (TTA) was introduced, which involves a discussion with the doctor for medicines on discharge, transcribing these onto the TTA and using ward based dispensing where possible. Results were collected pre and post implementation. Results Medication administration activity: Nurse time – 60 hours/month (medication administration and 2nd checking) saved. Discharge information: Proportion of TTAs dispensed at ward level increased from 19% to 78% post implementation, avoiding delays in dispensary. Average time writing TTA to being ready for discharge reduced from 280 min to 91 min. Drug listing reduced discharge time further to 52 min. Missed and delayed doses: Random sample of 5 patients audited over 48 hour period, shown to reduce missed doses from 14% to 0%. Comments from staff: ‘Because of skill mix and use of agency staff, assisting in preparing and giving IVABs has been a major help as on many days only 1 IV giver.’ ‘Junior staff value and support WFP and have felt has been useful to them.’ ‘Junior and agency staff feels better supported in understanding medicines usage’. ‘Lot of complex patients with many drugs, the pharmacist has helped reducing delay in administration times’. ‘TTAs[...]



    P30 The effects of introducing electronic prescribing for paediatric chemotherapy using aria on prescribing error rates at a primary treatment centre

    2018-01-19T07:28:36-08:00

    Introduction Prescribing of medication in children is a very complex process that involves an understanding of paediatric physiology, disease states, medication used and pharmacokinetics as well as patient specific details, their co-morbidities and their clinical condition. The most common medication errors have been identified as dosing, route of administration, and frequency of administration. Computerised provider order entry has been shown to reduce the number of prescribing errors related to chemotherapy as well as the likelihood of dose and calculation errors in paediatric chemotherapy prescribing. Locally, paediatric chemotherapy is prescribed on pre-printed paper prescriptions. Adaptation and implementation of ARIA electronic prescribing (EP) system for use in paediatric chemotherapy was undertaken by a Specialist Paediatric Oncology Pharmacist and was rolled out for use in January 2016 for patients with acute lymphoblastic leukaemia. Method The United Kingdom National Randomised Trial for Children and Young Adults with Acute Lymphoblastic Leukaemia and Lymphoma 2011 (UKALL, 2011) was developed for use on EP, with prescribing of all other chemotherapy remaining on paper. The number and type of prescribing errors were collected during a pre-implementation phase from January 2015 to June 2015. After the introduction of EP and following a 2 month acclimatisation period, a second period of data collection took place between March 2016 and July 2016. Overall prescribing error rates and the frequency of each error type were calculated both before and after implementation. Results Before the introduction of EP for paediatric chemotherapy, the overall error rate was 18.4% with a total of 16 different errors seen. Post implementation, overall error rate increased to 25.7% (p<0.001) with a total of 10 different errors seen. After introduction of EP, prescribing error rates on paper were 30.6% and on EP were 7.0% (p<0.001). Only 5 different error types were seen with electronic prescribing. The most commonly seen errors in prescribing with paper, both before and after were almost eliminated with the introduction of EP. Conclusion The introduction of EP has resulted in a significant reduction in prescribing error rates compared to paper based prescribing for paediatric chemotherapy. Overall the prescribing error rate increased after the introduction of EP but this was related to an increased rate on the paper prescriptions. One possib[...]



    4 Development of a workbook to guide pre-registration pharmacists through paediatric pharmacy training

    2018-01-19T07:28:36-08:00

    Aim To improve pre-registration pharmacist training and enthuse students in the area of paediatrics, within a teaching hospital. Background The pre-registration pharmacist training programme within the hospital allocates each student two weeks within paediatrics, which in the past has been poorly structured. During this time, the pre-registration pharmacist spent time shadowing pharmacists and accompanying them on ward visits. On occasions it was not always possible for the pre-registration pharmacist to accompany a pharmacist. In addition, some key paediatric medical conditions did not always present during their two weeks. Method To facilitate a more comprehensive training package a workbook, specific to paediatric clinical pharmacy was created. The booklet also contains brief introductory information about the wards and paediatric pharmacists, aims and objectives, and a reading list. The workbook is intended to be used as a ‘self-directed learning tool’, identifying clinical areas that the pre-registration student is expected to have a basic knowledge about, to help them prepare them for their exam and to give a good basic grounding in paediatrics. Different learning methods are used throughout the booklet to aid learning. The workbook includes, all with a paediatric perspective, common illnesses, immunisation, drug history taking, counselling children/parents, role of different members of the multi-disciplinary team, paediatric reference sources, calculations, renal function, pharmacokinetics in children, fluid prescriptions, use of unlicensed medicines in children, suitability of formulations, neonatal pharmacy and total parenteral nutrition. The students were briefed about the booklet at the start of their two weeks in paediatrics, and a discussion about progress at midway and at the end. Feedback was requested from each student (n=15), with a view to improving the booklet and enhancing their time spent within paediatric pharmacy. During the two weeks the students spent time in ‘general paediatrics’ and with specialist pharmacists, in tertiary paediatric services, experiencing the more complex pharmaceutical needs of these patients and the role of the specialist pharmacist. Results Feedback was received from eight students (53%). All of them had enjoyed the placement, found the booklet helpful in directing their learning and using their time productively, when they were unable to [...]



    P31 The effect of electronic prescribing on the incidence and nature of paediatric medication errors - an observational study

    2018-01-19T07:28:36-08:00

    Background Prescribing errors may adversely affect the safety of patients of all ages and particularly paediatric patients due to the complexity of calculating individual patient doses and the common need to use medicines not designed for children. Electronic prescribing systems (EPS) are an intervention used to try reduce such errors. Few studies have evaluated their impact on prescribing errors in the UK particularly in neonatal/paediatric settings. Aims To evaluate the nature and prevalence of prescribing errors in a UK children’s hospital which uses an EPS. To compare the results with those of a previous study1 conducted in the same hospital before the introduction of EPS. Methods Pharmacists were shadowed in their routine clinical work by the researcher who documented all prescribing errors identified. All electronic prescriptions checked for patients≤18 years in the paediatric wards were included in the data collection. Data was entered into a SPSS database for analysis. Types and severity of errors identified were categorised according to criteria used in a previous General Medical Council funded study (EQUIP).2 Results were compared to a previous study from 2012/2013 in the same hospital (4204 prescriptions) using the same method before the introduction of EPS. Results Observation of 4035 prescriptions checked by pharmacists on their routine ward visits (754 patients) during September-December 2015 identified 208 prescribing errors, an error rate of 5.2% prescriptions. There was a statistically significant difference between the rate of errors identified in this study compared to that found in the written prescriptions (8.7%) in the previous study (p<0.001). Fifteen errors (7.2%) were classified as serious; 106 errors (51%) significant and minor errors represented the remaining errors (data unavailable for previous study). The most common types of error identified were omission of regular medications (1.7% total prescriptions vs 1.6% in previous study); under-doses (0.8% vs 0.7%), non-measurable doses (0.7% vs 1.5%) and overdoses (0.5% vs 0.7%). Illegible prescriptions were reduced from 2% total prescriptions in the first study to zero by the EPS. Errors involving incorrect/missing administration times were also reduced from 0.9% in the previous study to 0.2% in this study. Antibacterial, analgesics and bronchodilators were the most common groups of drugs associ[...]



    P32 Pre-go-live simulation testing of new electronic prescribing systems in a specialist paediatric hospital

    2018-01-19T07:28:36-08:00

    Aim Single-site cross-sectional evaluation of a specialist paediatric hospital electronic clinical systems designed to support the medication process. This included simulation testing and evaluation of three electronic systems: PICS an electronic prescribing system designed in an adult hospital and being adapted for paediatric use; BDD an in-development electronic drug dictionary database that will serve as a clinical decision support tool; and Ascribe the existing pharmacy dispensing and management system (used to provide target levels). Simulation testing is used to assess the utility of the systems in the local (paediatric hospital) setting and gauge readiness for use in the live environment. Methods Unique drug regimens from consecutive hand written outpatient pharmacy prescriptions and the hepatology ward paper drug charts were harvested and used as the simulation test. Each regimen was therefore in current use at the study site. The test prescriptions were used to identify each systems’ ability to accommodate that regimen, such that: PICS (electronic prescribing system) – can the regimens be prescribed on PICS? BDD (drug dosing database) – are these regimens held within the database? Ascribe (hospital pharmacy system) – can the regimens be recorded on Ascribe to facilitate medication supply? The system tests were undertaken in early July 2015 following suitable training on how to use each of the three systems. Trained researchers attempted to enter the regimens into PICs and Ascribe; and to identify if the regimens were available within the BDD database. Approval was granted by the study site, and Aston University Ethics Committee. Results Outpatients (89 unique regimens) PICS: 74% (66/89) of drug regimens could be completely reproduced electronically, with 34% (30/89) matching default dosing regimens. BDD: 40% (36/89) of drug regimens were found in the database (drug name, indication, route and dose in relation to the age of patient) Ascribe: 77.5% (69/89) of drug regimens were reproducible and had labelling templates that existed on the system, a further 17% (15/89) drug regimens were available but required some amendment to existing templates. Hepatology ward – (126 unique regimens) PICS: 71% (90/126) could be prescribed as written on the drug charts. BDD: 58% (73/126) of drug regimens were found in the database[...]



    P33 Health information technology and the changing nature of medication errors in paediatric intensive care - a modified delphi process

    2018-01-19T07:28:36-08:00

    Aims The term ‘medication error’ has numerous definitions, impeding comparison between studies and is susceptible to subjectivity.1 The Delphi Process is widely used in health research to achieve consensus and has been previously used to define and specify medication error scenarios in both paediatric and adult settings.2,3 Novel technology-generated errors are emerging with increasing use of health information technology (HIT).4 Application of earlier Delphi studies to novel errors and those common in the prescribing of infusions in paediatric intensive care is limited. This study aims to achieve consensus on medication error scenarios identified in a paediatric intensive care unit (PICU) that have not been previously defined. Methods Stage 1 identified the scenarios requiring consensus. These were grouped into 3 error categories: electronic prescribing, smart-pump and prescribing of PICU infusions. Stage 2 selected a multidisciplinary expert panel using both purposive and convenience sampling. Stage 3 involved iterative rounds of consensus using paper-based and newer e-Delphi techniques. Participants independently scored on a 9-point scale their extent of agreement on the inclusion of each scenario as an error. Median and inter-quartile ranges were used to assess group consensus and to provide controlled feedback after each round. Results 19 scenarios requiring consensus were identified. A panel of 37 participants was selected, comprising of 15 doctors, 13 nurses and 9 pharmacists. 35 participants were from the study site, 1 pharmacist from a local PICU and 1 from a local NICU. Round 1 achieved consensus on 11 scenarios, increasing to 14 in Round 2. Round 3 consisted of 2 scenarios, both electronic prescribing related. Individual opinion on these was diverse, with 1 remaining equivocal after round 3. Some differences between healthcare professionals were found, but were only significant (p<0.05) for two and three scenarios in rounds 2 and 3 respectively. Conclusion The Delphi Process can successfully be employed to reach consensus on HIT-generated novel errors. The complexity of electronic prescribing systems is evident in the included errors and the difficulty in obtaining consensus. In contrast, the broad consensus reached on all smart-pump scenarios reflects the known risks associated with infusion pumps. The [...]



    P34 Successful introduction of an outpatient parenteral antimicrobial therapy (opat) programme in a large uk paediatric hospital

    2018-01-19T07:28:36-08:00

    Introduction An OPAT service was launched at large paediatric hospital in November 2014 to facilitate the safe and efficient discharge of patients from hospital into the community. The OPAT service is delivered by a multi-disciplinary team including a Consultant in Paediatric Infectious Diseases, an OPAT/Intravascular Access Nurse, an Antimicrobial Pharmacist, and involves collaborative working with community nursing teams across the region. We present an evaluation of our service based on audit data and patient feedback collected over a 12 month period. Methods Prospective audit using the BSAC p-OPAT (British Society of Antimicrobial Chemotherapy Paediatric Out-patient Parenteral Antimicrobial Therapy) database including data from 1 st January 2015 to 31 st December 2015. Results Two hundred and thirteen patients were admitted to the OPAT service leading to 1749 bed-days saved for the trust. Seventy-four patients avoided admission. The most common conditions were: bronchiectasis/chronic respiratory tract infection (15.5%), bacteraemia (15%), pre-septal cellulitis (15%) and respiratory tract infection (11.2%). Complex infections were less common but they accounted for longer antibiotic courses, such as cerebral abscess (5 patients – 170 days of intravenous therapy) and endocarditis (3 patients – 75 days of intravenous therapy).Using the BSAC outcomes definitions, we reported a 90% infection cure rate with a further 6.5% showing clinical improvement. OPAT outcomes were: success in 87% and partial success in 8.5%. The remaining patients (n=6) were classified as OPAT failures due to worsening of infection, drug reactions or inability to re-establish lost vascular access.Feedback from children and parents showed overall satisfaction with the OPAT service. Completed feedback questionnaires (n=30) rated the support and care as satisfactory or better in all cases, with over 83% rating the service as excellent. Conclusion We report a positive financial and clinical impact of a new paediatric OPAT service. The service expansion will focus on the involvement of new patient groups (oncology, general surgery) and the increase use of elastomeric devices allowing for an increase number of patients to be treated in their home environment. [...]



    P35 What clinical circumstances prompt hospital nurses to not administer a prescribed drug to paediatric patients?

    2018-01-19T07:28:36-08:00

    Aim At present pharmacists and pharmacy technicians aspire to extend their role to include administering medication to in-patients.1,2 The aim of this research was to identify clinical factors that arise in practice that lead nurses to intentionally not-administer (omit) prescribed drugs to paediatric patients. Understanding these actions is a pre-requisite to develop non-nurse administration of drugs to hospitalised patients. Methods Single-site, cross-sectional, qualitative study at a UK specialist paediatric hospital. The study instrument was semi-structured interviews (SSI) with hospital nurses who undertake drug administration roles. The interview questions were developed by sequential purposive discussions (4) with groups of hospital nurses. SSIs were conducted at a specialist children’s hospital that provides both local secondary and tertiary care. Interviews continued until data saturation was reached; this was when no new data was collected. The data was analysed using thematic analysis to identify the themes and subthemes present in the data; facilitated by NVivo software. Approval was granted by both the study site Research Manager and the University supervising the student. Results Ten SSIs were conducted one-to-one with paediatric nurses over a period of 2 weeks by the researcher. Eleven themes and twenty-five subthemes were identified in the data. Themes relating to reasons why prescribed drugs were intentionally omitted by nurses were: Drug rationale; ‘Frequency of administration’ errors/queries; ‘Timing of administration’; Choice of drug; Route; Dose regimen; Symptomatic relief not required; No access available – e.g. nil by mouth or no cannula in situ; Contra–indications; Blood results; Allergy. Examples of reasons why a nurse would omit a medication under the theme ‘contra-indications’ were: – if the patient’s clinical observations were out of range, if the medication was thought to interact with a concurrent drug or concurrent disease – e.g. if a drug would interact with a patient’s condition such as patient with renal problem and non-steroidal drug prescribed. Nurses would also omit medication based on blood results, if the prescribed drug had a narrow therapeutic index [...]



    P36 A review of aspirin discharge documentation in paediatric cardiology

    2018-01-19T07:28:36-08:00

    The humble drug Aspirin, derived from willow bark, is widely used in paediatric cardiology. It is used for a number of different indications mainly for its antiplatelet action; a few such examples include Blalock-Taussig shunts, Glenn shunts, post ablation stroke prevention and in Kawasaki Disease.

    The discharge summary is a means of communicating changes to GPs, other hospitals and paediatricians within the paediatric cardiac network. The aim of the review was to assess the situation currently; whether the indication and duration of aspirin were documented on the patient’s discharge summary. This issue has been raised through our paediatric cardiac network meeting.

    A retrospective study was carried out. A list of all patients discharged from the paediatric cardiac ward in January & February 2016 was obtained from Medway; our electronic patient information system for admissions and discharges. Using this list of patients, Heartsuite; our electronic cardiac database, was used to find 30 patients, who were discharged on aspirin.

    The following data was collected on each of these discharge summaries; whether aspirin was newly started or continued, whether the indication and duration of aspirin was documented.

    The data was collected and of the 30 discharge summaries viewed with aspirin on discharge; 18 (60%) were newly started on aspirin and 12 (40%) were continued on aspirin, 4 (13.3%) had the indication documented and 12 (40%) had the duration documented.

    The paediatric cardiac patients discharged on aspirin, as shown by the results in this review show that the majority of discharge summaries do not have the indication or duration of aspirin documented. So, there was found to be inadequate documentation and communication to users in our paediatric cardiac network. With this in mind a service improvement is necessary.

    The improvement suggestions are two-fold. Firstly, an additional note needs to be made to the surgical operation note that can be transferred to the discharge summary. Secondly, the addition of a mandatory field on the medication section of the discharge summary for the indication and the duration of aspirin.




    P37 A single paediatric centre experience of l-carnitine supplementation in medium-chain acyl-coa dehydrogenase deficiency (mcadd)

    2018-01-19T07:28:36-08:00

    University Hospitals Bristol Aim The aim of the project was to establish whether patients with MCADD treated at Bristol Royal Hospital for Children (BRHC) are supplemented with l-carnitine and to establish further details for supplementation. Background MCADD is the most common type of fatty acid oxidation disorder in the UK.1l-carnitine is a co-factor in the oxidation of fatty acids in mitochondria and eliminates excess medium chain fatty acids. l-carnitine supplementation in MCADD is controversial with no consistent findings in publications.2 Methods The paediatric metabolic database at BRHC was interrogated to find the number of patients with MCADD. Patients who were either deceased or discharged from the metabolic service were excluded. Medical notes and pharmacy records were reviewed for each patient to determine patient demographics, dosing information and reasons for implementation of l-carnitine using a data collection tool which was piloted on the first 5 patients. The data was analysed using Microsoft Excel. Results Of 35 patients treated for MCADD, 13 patients (37%) received l-carnitine. The most common age group treated was 6–10 years (n=6). The mean dose of L-carnitine=77.7 mg/kg/day; range 45–100 mg/kg/day; most common dose=100 mg/kg/day (n=6). 92% of patients received the 300 mg/mL liquid. Of the 13 patients, 1 had low free carnitine but was asymptomatic; 8 were symptomatic with low levels and 3 were symptomatic with borderline low levels and 1 had no reason documented. All symptomatic patients improved with therapy. Those who stopped supplementation on correction (n=3), all restarted due to return of symptoms with falling levels. 2 of these patients have a vegetarian diet, a reason for low free carnitine. 2 patients had their doses reduced from 100 to 50 mg/kg/day due to side effects, particularly fishy body odour exacerbated by hot weather. 1 patient complained of the same effect, but the dose remained the same. Conclusion The majority of patients in this centre are not treated with l-carnitine. The reason for treatment is mainly low free carnitine associated with symptoms. Clinical and biochemical improvement was observed with treatment. The most common dose prescribed was 100 mg/kg/day; [...]



    P38 Clinical pearl: pharmaceutical management of primary erythromelalgia (pe) (scn9a)

    2018-01-19T07:28:36-08:00

    Situation Patient RL is a 7 year old female with a confirmed genetic diagnosis for Primary Erythromelalgia PE, with a heterozygous sequence change in the SCN9A gene: c.2623C>G, p.(Gln875Glu). This genetic mutation of SCN9A results in sodium chanellopathy specifically for the voltage gated sodium channel Nav1.7. This genetic mutation makes the Nav1.7 channel hypersensitive to stimulus and over activation.1 As a result, she suffers from severe intermittent episodes of bilateral erythema and burning pain of the lower limbs. These symptoms are difficult to manage and PE is also known as ‘man-on-fire syndrome’.1 Background PE in a child is a complex diagnosis with severely limited pharmacological treatments available. Inadequate pain relief was achieved with routine analgesics such as paracetamol and ibuprofen. A multidisciplinary team (MDT) approach including pharmacy was implemented with; review of available literature, alternative medications for relief of pain and other PE symptoms, advice on formulation and dosing. Outcome When initially diagnosed, RL was frequently admitted to hospital for uncontrollable and pain and the family were unable to manage at home. Since her diagnosis and full MDT involvement, her pain relief has improved, her hospital admissions have decreased and her family are coping better at home. However, despite pharmacological interventions she is still not entirely free from pain and her other symptoms. Patient RL has also received intensive psychology input for coping strategies in managing her pain, and her parents have received psychological and social input to help them. She is managing to walk more and but still relies on her pushchair. Her current medication regimen is as follows: gabapentin, cetirizine, chlorphenamine, naproxen, paracetamol, clonidine, mexiletine, amitriptyline and topical application of amitriptyline and ketamine. Unsuccessful treatments included: magnesium supplementation, menthol in aqueous cream, lidocaine patches, tramadol and aspirin. Lessons learnt There is little information in the literature on the treatment of paediatric patients with PE and they are mainly case reports. Management of RL has been multidisciplinary with pharmac[...]



    P39 Start smart: improving the quality of empiric antimicrobial prescribing at a tertiary paediatric hospital

    2018-01-19T07:28:36-08:00

    Appropriate choice of empiric antibiotic therapy, in line with local guidelines, improves outcome for children with infection, while reducing adverse drug effects, cost, and selection of antimicrobial resistance. Data from national point prevalence surveys showed compliance with local prescribing guidelines at our hospital was suboptimal. A team with representatives from the pharmacy, microbiology and emergency departments collaborated with prescribers to improve the quality of empiric antibiotic prescribing. The project aim was, using the ‘Model for Improvement’, to ensure ≥90% of children admitted via the Emergency Department (ED) and commenced on antibiotic therapy, have a documented indication and a choice of therapy in line with local antimicrobial guidelines. Method Results of weekly audits of the first ten children admitted via ED and started on antibiotics were fed back to prescribers. Front line ownership techniques were used to develop ideas for change, including; regular antibiotic prescribing discussion at Monday morning handover meeting, antibiotic ‘spot quiz’ for prescribers, updates to prescribing guidelines (along with improved access and promotion of prescribing app), printed ID badge guideline summary cards, reminders and guideline summaries at point of prescribing in ED. Collection of audit data initially proved challenging, but was resolved through a series of rapid PDSA cycles. Initial support from ED consultants and other ED staff facilitated establishment of the project. Presentation of weekly run charts to prescribers fostered considerable support among consultants and non-consultant doctors (NCHDs). We saw a shift in perspective from ‘how is your project going?’ to ‘How are we doing?’. Results Documentation of indication and guideline compliance increased from a median of 30% in December 2014/January 2015 to 100% consistently from February 2015 to the present. It is felt that a change in approach to antimicrobial prescribing is now embedded in our hospital culture as this improvement has remained constant through three NCHD changeovers. A comparison of 2014 Antimicrobial expenditure to 2015 fig[...]



    P40 The effect of a pharmacist-led inhaler technique assessment, education and training intervention on asthma control test scores in a paediatric hospital outpatient setting

    2018-01-19T07:28:36-08:00

    Background Studies have consistently demonstrated that the correct and effective use of inhaler therapy reduces the frequency and severity of asthma symptoms and thus improves asthma control. Pharmacists are particularly well positioned to educate and train patients in the correct use of their inhaled therapy.1 They are often the last healthcare professionals to have contact with patients prior to the use of prescribed inhaled medication.2 This places pharmacists in an opportune situation for patient counselling with regard to inhaler technique. An extensive literature search revealed that pharmacist-led inhaler technique assessment and training has not, to my knowledge, been carried out in the paediatric population in a hospital setting. Aim To determine if pharmacist-led inhaler technique assessment, education and training improves asthma control scores in the paediatric population (4–16 years). Method This prospective single-centre interventional study was undertaken in patients with a confirmed diagnosis of asthma between the 1 st April and 30th June 2014. Those prescribed inhaled therapy prior to attendance at clinic, were referred to the investigating pharmacist. Patients with concurrent respiratory conditions and those under the age of four were excluded. The pharmacist delivered structured inhaler technique assessment and practical training with regard to correct inhaler technique. Additional educational advice was provided and baseline asthma control scores recorded. Results The results of this study show that inhaler technique assessment, education and training in a single session by a hospital based clinical pharmacist significantly improved ACT scores [Baseline Score=19.33±3.312, Follow-up Score=21.75±2.701, (p=0.04)] and cACT scores [Baseline Score=19.50±4.993, Follow-up Score=21.04±4.647, (p=0.047)]. Conclusion This study shows feasibility and potential for clinical pharmacists in the hospital healthcare setting to provide inhaler technique assessment, education and training for patients with asthma. This study also provides a unique insight into a snapshot of the paediatric population with ast[...]



    5 Standard iv infusion concentration in paediatric and neonatal units: a national survey

    2018-01-19T07:28:36-08:00

    Aim The National Patient Safety Agency in the UK has advocated the use of standard concentration (SC) infusions to improve patient safety and care.1 National standards have been adopted for infusions in the adult critical care setting however practice in paediatric and neonatal settings still varies and presents a challenge.2,3 This study is part of a multi-professional collaborative working towards a national consensus on SC infusions in paediatric and neonatal care. The study aims to explore the practice of standardised concentration usage for Intravenous (IV) infusions in paediatric and neonatal units in the UK, specifically: How many units use standardised concentration for IV infusions. Evaluate the variation and overlap of continuous IV infusion concentrations in practice. Assess what devices are used to administer these infusions. How standardised infusions are provided. Method The study used a quantitative descriptive survey design via an online self-administered questionnaire. Paediatric and neonatal intensive care units in the UK were surveyed through pharmacy, nursing, and medical networks to describe current practice. Data was collected for 25 days and analysed using SPSS. Result A total of 194 NICUs and 39 PICUs were surveyed. Responses were received from 71 units: NICU 46 (65%); PICU 17 (24%) and 8 other (11%), giving an overall response rate of 30.5%. Twenty-eight units (40%) have established SC for IV infusions, 18 units provided information on presentation of SC infusions. Forty-six different medication infusions were standardised. Considering the differences in concentration, weight-bands, diluents, volume and presentation, there were 273 variations for these drugs. Taking only the concentration into account, there were 137 variations presented. The average number of variations per medication was 3 (range 1 to 14). 15 units (53.6%) use ‘smart’ pumps for administration of SC infusions and 3 (10.7%) use other computer software for infusion rate calculations. Infusions are most commonly prepared on wards (81.3%) or in pharmacy (12.3%). Conclusion The study is limited by the response rat[...]



    6 Medicines in schools - a survey of stakeholders

    2018-01-19T07:28:36-08:00

    Aim To determine the perspectives of stakeholders on how children’s medicines are dealt with in schools. Methods Stakeholders were children with long-term conditions or receiving intermittent medicines and their families, school staff and healthcare professionals. Between August 2015 and July 2016, children on long term therapy and their parents/guardians completed a paper-based questionnaire. Parents of children receiving intermittent medicines took part in a telephone survey. Other stakeholders completed electronic questionnaires. Questions related to medicine type, administration, storage, record-keeping, staff training, communication and problems encountered. Quantitative data are presented using summary statistics, free text responses were categorised by theme. Results Responses were received from 59 healthcare professionals, 24 parents of children with long term conditions and 15 children with long term conditions, 10 parents of children receiving intermittent medicines, 40 school staff and 11 school nurses. The age range of the children who completed the questionnaire (or had it completed by their parent) was 4–16 years. The number of regular medicines taken at school ranged from 0 to 4, the number of medicines taken at school when required ranged from 0% to 12. 72.5% of school staff respondents were from primary schools (±nursery), 20.0% from secondary and 7.5% from schools for pupils with special needs. Children needed to take oral and buccal medicines, inhalers, nebulised treatment, topical, rectal and injectables at school.57.6% of healthcare professional respondents were aware of problems encountered by patients with medicines at school. 47.1% of school staff respondents said there were challenges with the administration of medicines. 52.5% said there was some room for improvement in how they managed medicines at their school. 54.5% of school nurse respondents were aware of problems with medicines at school. 41.7% of parent and 66.7% of child respondents reported at least one problem. Four parents of children receiving intermittent treatment said that their c[...]



    7 Development of a leaflet to teach children to swallow tablets

    2018-01-19T07:28:36-08:00

    Aim In paediatric pharmacy a wide range of medications are used, which are often not available in formulations suitable for children. We wanted to design a tool that would enhance our patients’ experience of medication taking as well as improving accessibility to medicines, palatability and ease of administration. Method The European Medicines Agency advises that ‘for chronic diseases, the acceptability of tablets in children may be improved by adequate training’.1 Among others a study has shown that almost half of two year olds could swallow a 3 mm tablet, increasing to 85% in 5 year olds.2 A leaflet was suggested as the best way to teach our patients and their parents how to swallow tablets as it could be widely distributed. It was developed with a working group of paediatric clinical psychologists and a paediatric pharmacist. The leaflet aims to be encouraging and provide practical tips and advice. It offers seven different techniques for swallowing tablets which were adapted from web-based advice and previous cases. The leaflet was piloted in a small number of patients and they were given a questionnaire. Results Ten questionnaires were returned, with patients’ ages ranging from 5 to 17. All the patients said that they would now be taking all or some of their medication as tablets. All of the techniques were tried by 2 or more patients and each technique was successful for at least 1 child. The most popular method was the ‘big gulp method’ which worked for 8 patients. This involves swirling the tablet around the mouth for 10 s with as much water as possible and then taking a large gulp until all the water and the tablet have gone. Positive feedback for the leaflet included ‘feels grown up being able to take a tablet’, taking tablets is ‘easier’ and ‘quicker’; one patient wished they had been given the leaflet sooner. Parents also fed back that ‘there was no longer a fight to take medicines’ and ‘it’s much easier for school to manage’. Conclusion The findin[...]



    8 Convection enhanced delivery of carboplatin for the treatment of diffuse intrinsic pontine glioma: the pharmacists perspective

    2018-01-19T07:28:36-08:00

    Situation To ensure safe delivery of carboplatin by convection enhanced delivery (CED) for the treatment of diffuse intrinsic pontine glioma (DIPG). Background CED describes a method of direct drug delivery to the brain parenchyma through surgically placed microcatheters, completely bypassing the blood brain barrier (BBB)1 Drug is infused with precisely controlled low infusion rates that create a pressure gradient that displaces the brain extracellular fluid with infusate.2 DIPG is a malignant high grade brain tumour of children. The median survival is only 9 months1 and no systemic treatment to date has been effective.1 This is likely due to the fact that the majority of systemic therapies do not cross the BBB to achieve a therapeutic concentration within the tumour.1 CED overcomes these limitations and has the potential to achieve a therapeutic drug concentration within the tumour without causing any systemic toxicity.1 The unique surgical technology developed in our department, allows repeated infusions of drug without the need for further surgery. The challenges faced by pharmacy were to ensure that an appropriate policy and register was developed to ensure that all professionals involved in the handling, prescription, preparation and administration of carboplatin by CED are appropriately trained and informed, and that patients receiving this therapy are safe. This follows the Department of Health guidance on the safe administration of intrathecal chemotherapy.3 This also had to be reflected on the prescription chart that was designed specifically for CED. It was necessary to ensure that carboplatin was stable at differing concentrations in the diluent used, artificial cerebrospinal fluid, and to determine the shelf life. Outcome CED of carboplatin has been administered to 8 patients (ages 4–12 years) under compassionate use.4Patients were infused with up to 9 cycles of carboplatin for two consecutive days at a concentration of 0.18 mg/ml which were well tolerated, with neurological side effects most commonly seen during t[...]



    9 Children/young people taking long-term medicines - a survey of the experiences of community pharmacists

    2018-01-19T07:28:36-08:00

    Aim To identify the experiences of community pharmacists in caring for children/young people, or their parents/carers, taking long-term medicines. Method A pre-piloted 13 point semi-structured survey, participant information leaflet, consent form and pre-paid return envelope were posted to all 354 community pharmacists who had dispensed a prescription from a single specialist paediatric hospital during November and December 2015. Community pharmacy addresses were obtained from the National Health Service Business Services Authority ePACT system. Telephone follow-up of non-responders and, if necessary, a repeat mailing was made from 3 weeks after the original return by date. Participants were asked about their experiences of undertaking a medication review with either children/young people or their parents/carers, medication-related problems presenting to them, adherence, information needs of patients/carers and what issues were reported to them from this group. The data were analysed using SPSS version 22 and NVivo version 10. Results A response rate of 76/354 (21.5%) was achieved. Eighteen (23.7%) respondents had undertaken a Medicines Use Review (MUR),122 (28.9%) a New Medicines Service (NMS)2 review and 16 (21.1%) had undertaken another type of medication review in a child/young person. Respondents reported that patients or their carers had presented to them with adherence issues including stopping the medicine (24, 31.6%) and changing the dose (28, 36.8%) without informing the prescriber. Patients or their carers had requested information from them about the indication (59, 77.6%), dose regime (63, 82.9%), administration (64, 84.2%) and adverse effects (58, 76.6%). Respondents also reported patients/carers experiencing difficulties obtaining further supplies of a medicine from their community pharmacy (47, 61.8%) and patients’ general practitioners declining to prescribe a medicine recommended by the patient’s hospital-based specialist (27, 35.5%). Conclusion This study has demonstrated that c[...]



    P2 Interventions to improve safety of parenteral nutrition use on a paediatric intensive care unit

    2018-01-19T07:28:35-08:00

    Aim Parenteral nutrition is a high risk treatment, and under- or over-infusion can have serious consequences for patients. Following several errors where parenteral nutrition (PN) was administered at incorrect rates, including incidents of vamin and lipid rates being switched, we aimed to reduce errors causing harm related to PN prescribing and administration. Method The local incident reporting system was used to identify errors and trends involving PN. The most common errors involved incorrect rates being either prescribed or administered. A series of interventions were developed between March 2014 and December 2015 aimed at reducing errors. Unit staff were surveyed and PN bag changeover was moved from day to night shifts. The nursing PN administration guideline was updated and relaunched to reinforce the correct procedure. Usual practice on the unit is for nurses to titrate PN to maximum rates according to fluid allowance. Prescription rates were audited, multidisciplinary team (MDT) staff surveyed and daily prescribing of administration rate ranges was implemented with MDT support. PN education sessions were targeted at all staff via a short ‘bootcamp’ format repeated over three weeks and a session at weekly medical teaching. The sessions covered general information, risks and examples of both common and serious errors. Results Planned changes were accepted and supported by the unit staff. The initial prescription audit found 100% of patients had inaccurate rates prescribed and 43% of patients had rates running above those prescribed. Re-audit of prescriptions following the change showed that the correct rate ranges were being updated daily and PN was administered at or below maximum rates. Through the bootcamp sessions we identified some areas of confusion and variations in practice; the administration guideline was further updated as a result. Error monitoring showed an initial increase in reported errors for 2015. These were mainly near miss reports (no harm) b[...]



    P3 S.a.f.e. - the positive impact of 'druggles on prescribing standards and patient safety within the neonatal intensive care environment

    2018-01-19T07:28:35-08:00

    Introduction Situation Awareness For Everyone (S.A.F.E)1 is a two year programme led by the Royal College of Paediatrics and Child Health in partnership with NHS hospitals, to aid the development of a range of quality improvement techniques with the aim of reducing preventable deaths and errors occurring in the UK’s paediatric departments. The neonatal unit began daily safety huddles to identify ward risks and share learning points in September 2015. An NHS Trust piloted the ‘druggle’, a ‘ward-based safety huddle’ with ward pharmacist, doctors and nurses, as part of the S.A.F.E project, on their neonatal ward in July 2015. Aim The aims of the druggles are to increase communication between pharmacists, the medical team and nursing staff, and to educate all staff regarding specific drug related topics. They enable the team to receive feedback on anonymised errors in real time, draw attention to areas for improvement, encourage discussion and share learning points from them. Method The druggles were developed as drug related safety briefings. They are presented once a week as part of the daily huddle. The basic format of the sessions is a weekly ‘hot topic’, for example recent BNFc changes, an ‘error of the week’ and celebration of good prescribing practice. Themes are identified by members of staff and discussed at the druggles as they arise. This enables timely education and discussion of topics as they occur. The neonatal pharmacy team completed a baseline prescribing standards audit in February 2016 (after the induction of the new medical team) which will be repeated before the doctors rotate in August. This audit provided information about common prescribing errors and helped to identify possible ‘hot topics’ for discussion. A ‘zero tolerance’ audit of 5 randomly chosen prescription charts is completed weekly to assess prescribing standards in real time. A chart ‘fails&rs[...]



    P4 Outcome following switch between brand name and generic tacrolimus in paediatric population

    2018-01-19T07:28:35-08:00

    Introduction Generic preparations of drugs are often cheaper than brand names and offers significant cost benefits. For many medicines, a switch between preparations can be done with little or no monitoring. Tacrolimus prescription, however, provides an interesting challenge due to its narrow therapeutic window and requires careful medical supervision and therapeutic monitoring while switching. Adoport1 is a generic tacrolimus preparation introduced to the market after the exclusivity period for Prograf2 ended. At present there is limited evidence to show the effects of the switch between formulations in paediatric patients. In 2015, Nottingham Children’s Renal Unit undertook to switch all existing paediatric kidney transplant and nephrotic patients on Prograf to Adoport and we herewith present the effects on patients and their Tacrolimus levels. Method Prescriptions for tacrolimus are dispensed and delivered by a homecare provider on a three monthly basis. Patients were given written and verbal advice to switch from Prograf to the same dose of Adoport two weeks before their next clinical appointment. After taking a stock of their existing Prograf supply, a prescription was given to ensure the patient did not run out of Prograf until their switch date and had enough Adoport until the following prescription was due. The Tacrolimus level was then reviewed by the patient’s doctor at their clinic appointment and dose adjustments were made if necessary as per standard of care. We reviewed data for Tacrolimus levels in the 3 months before and after the switch and assessed for any clinical variation in immunosuppression. Results 36 patients were switched from Prograf to Adoport. One patient developed hair loss and requested to go back onto Prograf, all other patients tolerated the switch well. There was no significant change in the tacrolimus levels of the population following the switch (p=0.02). There was no significant ch[...]



    P5 A case report: dihydropteridine reductase deficiency and the efficacy of replacement with a nutritional supplement from of 5-hydroxytryptophan

    2018-01-19T07:28:35-08:00

    Introduction Dihydropteridine reductase (DHPR) deficiency is an autosomal recessive genetic disorder where the synthesis of tetrahydrobiopterin (BH4) is affected. BH4 is an essential co-factor for the hydroxylation of the aromatic amino acids; phenylalanine, tyrosine and tryptophan. A deficiency of BH4 results in hyperphenylalaninaemia, and a lowered synthesis of dopamine and serotonin and therefore low levels of cerebrospinal fluid (CSF) neurotransmitters cause the clinical symptoms. Patients with DHPR deficiency may present with hypotonia, abnormal movements, poor temperature control, irritability, seizures, progressive developmental delay and microcephaly. Long term amine replacement with 5-hydroxytryptophan and levodopa, the respective precursors to serotonin and dopamine, is the main treatment to supplement CSF neurotransmitters, and diet restriction of phenylalanine. Folinic acid is also given to prevent CNS folate deficiency. Case report This patient was born by caesarean section at 39 weeks and detected through newborn screening with an elevated phenylalanine level of 634 micromol/l and later a confirmatory repeat level was 850 micromol at the age of 12 days. Subsequent tests confirmed a defect in biopterin recycling due to DHPR deficiency. The patient did not show any symptoms and looked well but the guidelines are to commence treatment and regular monitoring of the treatment. The doses started were levodopa as co-beneldopa dispersible tablets (benserazide 12.5 mg and levodopa 50 mg) initially 1 mg/kg in 4 divided doses, 5-hydroxytrptophan 1–2 mg/kg in 4 divided doses, calcium folinate 15 mg OD and a low phenylalanine diet. Doses were adjusted in response to the lumber puncture CSF results. During this time the patient was developing but was a little behind on some milestones especially speech development, some challenging behaviour and during this period of time the parents reported that[...]



    P6 Intervention monitoring in maternity and paediatrics as a strategy to guide education and improve prescribing practice

    2018-01-19T07:28:35-08:00

    Aim This audit explores the impact of regular pharmacist intervention monitoring and feedback on paediatric and maternity wards, and how these interventions guide educational strategies aimed at improving prescribing practice. Method A tally-chart data collection tool was designed for each ward to collect data on common errors such as omission of booking weight, vital to ensure safer prescribing of dalteparin, omission of dose/kg imperative to ensure safer paediatric prescribing, and also omission of the residing ward from the front of the chart which affects discharge times when TTOs are delayed/lost due to misdirection. The ward pharmacist recorded the incidence of these errors during each daily visit and prepared a weekly feedback report consisting of a bar graph of the results plus a comparison to the previous week. The pharmacist would also reiterate the importance of avoiding each type of error. This would also inform the topic of the ‘key prescribing message’ (a bulletin focussing on a particular type of error) explaining the correct method and the significance of avoiding errors. This was communicated to the ward teams/prescribers. Results Preliminary audit data is encouraging and shows that the feedback to the ward teams has had a positive impact. Many nurses and midwives were surprised at the level of errors and now better understand their significance and how they can support accurate prescribing. The senior medics have taken an interest in the audit and are keen on sharing the information with their juniors and adapting their training to ensure that further improvements are made. The data collected informed the first ‘key prescribing messages’; ‘Booking weight’ for maternity and ‘medicines reconciliation’ for paediatrics. Since these were communicated to the ward teams/prescribers the audit has found an improvement i[...]



    P7 An audit of the management of resuscitation drugs and trolley contents

    2018-01-19T07:28:35-08:00

    Introduction Every clinical area is equipped with either a resuscitation trolley containing a red emergency drug box (2222 box) or only the 2222 box for emergencies such as cardiac arrests. According to national1 and local guidelines each of these trolleys contains a certain set of drugs and a CD size oxygen cylinder. Aims were to audit compliance of drugs, including the medical gas oxygen, with national1 and local guidelines to audit compliance with the required daily check of resuscitation trolleys and 2222 boxes to audit frequency of expired medicines to audit compliance with up to date resuscitation guidelines The aims of the audit were to assess the pharmaceutical contents in the resuscitation trolleys, monitor if regular checks are done to the trolleys, compare the pharmaceutical contents in the trolleys to those on the local clinical area’s stock list and review the resuscitation guidelines on the trolley. Method A data collection form was created which included the drugs and local Trust resuscitation trolley content list. A free text box was included to capture drugs or drug related guidelines found on the trolley that were not officially listed. Results Forty seven clinical areas were included in the data collection, 32 held a resuscitation trolley and a 2222 box, 15 held a 2222 box only. Compliance of drug content: 50%. Reason found for poor compliance was that most clinical areas (84.4%) did not keep 250 ml sodium chloride bags as routine stock on the ward causing a delay in replenishing following an emergency. Twenty of the trolleys contained drugs not included on the list. Compliance with equipment list Compliance of Oxygen cylinders on trolley: 5/29. Critical care unit trolleys did not keep oxygen cylinder as each bed space keeps a cylinder. One cylinder was found out of date. Compliance rate with daily trolley checks: 29/32[...]



    P8 Chemotherapy standardisation in paediatric oncology: the our ladys childrens hospital (olch) dublin experience

    2018-01-19T07:28:35-08:00

    Background/objectives Several centres (Children’s Hospital Philadelphia, Sick Kids Toronto) and organisations (COG) have developed chemotherapy standardisation programmes to reduce risk, increase efficiency and decrease cost associated with the presciption, preparation and administration of chemotherapy in paediatric patients. Most European paediatric chemotherapy protocols use different doses, infusion times, hydration protocols and supportive medicine doses for the same drugs. There is huge variety in how individual patients receive the same drugs. This introduces significant, unnecessary, potential risks and complexity. By 2016 our aim is that all children at our institution should have chemotherapy prescribed, prepared and administered according to a standard institutional protocol. Design/methods We set up a multi-disciplinary chemotherapy standardisation group within our department. The project was developed in association with a hospital quality initiative. We reviewed all treatment protocols in use at the current time at OLCH and assessed the variety in chemotherapy administration. We performed staff and parental questionnaires regarding their perceptions of the variety in administration, supportive medicines and discharge times. We held a meeting of all senior departmental management to review and critique the project and multiple staff education sessions to implement the recommended changes. Results There is huge variation in how European protocols mandate that chemotherapy be administered, particularly in protocols using doxorubicin, cisplatin, ifosfamide and cyclophosphamide. We have developed a standard, institutional document which determines how chemotherapy and supportive medicines are administered, limiting variation and risk, increasing staff efficiency and decreasing lengths of hospital admissions[...]



    P9 Paediatric prescribing: boosting the basics to reduce errors

    2018-01-19T07:28:35-08:00

    Aims To monitor the adherence to defined quality standard of prescribing in paediatric practice within Western Sussex Hospitals NHS Foundation Trust (WSHT). By identifying deficient areas, teaching and training can then be tailored to improve performance and safety. Method A prospective audit of paediatric drug charts was performed at both WSHT sites (St Richards and Worthing General Hospitals) once weekly over a one month period. Drug charts were excluded only if no medications were yet prescribed. 22 patients audited from St Richard’s (SRH) and 34 from Worthing (WGH) were audited. Doctors within the department were aware the audit was ongoing and received feedback during the audit period about areas where improvement was needed as it would be unethical to not address prescribing issues in a timely manner. Data was collected using a standardised list of ten quality standards: Completion of all patient demographic information Whether all prescriptions are legible Completion of allergy section Appriopriate prescribing unit use Ensuring all antibiotics have a written duration and indication Any patient on oxygen must have it prescribed No unapproved generic medications names All PRN medictions should have dose and maximum frequency Prescribers need to sign and stamp prescriptions Perfection: All quality standards met. Results The majority of quality markers were well adhered to. Criteria of legibility, allergies, appropriate unit use, PRN dose and frequency, signed and stamped were met in over 90% of the charts audited at both sites. Demographic information was consistently poorly completed over both sites (SRH=59.1%, WGH=61.8%) and antibiotic duration/indication completion was particularly poor in St Richard’s Hospital (64.3% at SRH vs 95% at WGH). Very few patients audited w[...]



    P10 To give, or not to give...

    2018-01-19T07:28:36-08:00

    Aim ‘Between September 2006 and June 2009, the NPSA (National Patient Safety Agency) received reports of 27 deaths, 68 severe harms and 21 383 other patient safety incidents relating to omitted or delayed medicines’.1 The Trust’s Medicines Code states that ‘critical’ medicines should be administered within one hour of the prescribed times, and all other medicines within 90 min.2 ‘Critical’ medicines relevant to NICU (Neonatal Intensive Care Unit) patients include injected antibiotics, anticoagulants, anticonvulsants, aminophylline infusions and strong opioid analgesics. The aim of this audit was to establish what proportion of medicines prescribed for patients on NICU were given outside of this policy. Method Data was downloaded for all NICU inpatients from the electronic prescribing system, ICCA, from 1/4/16 to 30/6/16 inclusive. It was then analysed using Excel. The data shows details of all regular drugs prescribed, the scheduled administration time and the time that the nurses recorded that the drug had been administered. Once only, when required and drug infusions longer than 4 hours were all excluded from this data capture. Scheduled doses of antibiotics that were intentionally delayed whilst awaiting levels, e.g. vancomycin and gentamicin, were excluded before data analysis. Results It was found that over the 3 month period, 137 different patients were administered 10 642 regular doses of 51 different medications. 5.86% of these were classified as ‘delayed’ according to Trust policy. 97.6% of these delayed ‘critical’ medications were antibiotics, accounting for over 45% of the total delayed doses. Meropenem was found to be the antibiotic most frequently delayed, with over one quarter of all doses [...]



    2 The impact of health information technology on medication errors in a paediatric intensive care unit

    2018-01-19T07:28:36-08:00

    Aims Health information technology (HIT) is increasingly being promoted as a medication error reduction strategy. Electronic prescribing and smart-pump technology are examples of HIT widely advocated in the hospital setting. In critical care, the risks associated with paediatric infusions have been specifically addressed with calls for the use of standard concentration infusions (SCIs) in conjunction with smart-pump technology. Evidence on the benefits of HIT in the paediatric setting remains limited. This study aims to assess the impact of both electronic prescribing and a smart-pump drug library of SCIs on medication errors in paediatric critical care. Methods A retrospective, observational study based on an interrupted time series design was conducted in the 23-bed paediatric intensive care unit (PICU) of a tertiary children’s hospital. 3400 randomly selected medication orders were reviewed over 4 epochs: pre-implementation of either technology (Epoch 1); post-implementation of SCIs (Epoch 2); immediate post-implementation of electronic prescribing (Epoch 3); and 1 year post-implementation of both (Epoch 4). Orders prescribed during the study period were included provided they had undergone clinical pharmacy review. Intravenous fluids, epidural/regional blocks, total parental nutrition, chemotherapy and patient/nurse controlled analgesia were excluded. Medication error rates were calculated applying pre-specified definitions and inclusion criteria.1 Novel technology-generated errors were identified and defined using a modified Delphi process. Errors were graded for severity using a combination of two validated grading tools.2,3 Results Overall medication error rate based on all orders were similar in Epoch 1 and 4 (10.2% vs 9.7%; [...]



    P11 Improving the completion of the medication prescription and administration record on a paediatric ward

    2018-01-19T07:28:36-08:00

    Introduction The Medication Prescription and Administration Record (Kardex) must always be legible and complete. It is this initial point of prescription writing that opens the way for errors and delays to delivery of treatment to occur due to omitted or misinterpretation of the prescription.1 A Regional Safety Forum introduced a Paediatric Safety, Quality and Improvement Collaborative in November 2013, where the local Trusts could come together to learn about new initiatives and discuss ongoing projects. One area our Trust felt was important and decided to explore was medication safety, starting with medication prescribing. Overall aim The aim of this project is to examine how well the kardex is being completed and how it can be improved. Methods Data collection was commenced in September 2014 by the paediatric pharmacist. A weekly kardex review audit was carried out looking at two areas: The correct completion of the front of the kardex (against 7 criteria – patient name, hospital number, date of birth, allergy status, ward, weight, date of weight). The overall prescription writing error per drug (against 17 criteria). Five kardexes each week were audited and were selected randomly from the current in-patients. An education intervention was a poster for the ward to highlight best practice prescribing guidelines. The initial 4 week results were presented at the next Paediatric Learning Session. Any particular areas of concern were fed back to the medical staff on the ward. Data collection continued to determine if there was any improvement with medical staff being aware of the audit and also with the poster being prominently displayed on the ward. Results In September 2014 the accurate completion of the[...]



    P12 An audit on the use and monitoring of azathioprine (aza) in a paediatric gastroenterology centre. could nhs england via specialist commissioning rules (nhs-e-spr) be affecting quality of care?

    2018-01-19T07:28:36-08:00

    Aim To explore the centre’s adherence to the British Society of Gastroenterology Hepatology and Nutrition (BSPGHAN) guidelines1 regarding AZA use and monitoring and to suggest solutions in the event that substandard level of care is identified. Methods Data was collected on 110 gastroenterology patients (October 2014 to January 2016) on AZA from the dispensing and medicine management systems. They included patient demographics and the eleven basic AZA monitoring points recommended by the BSPGHAN guidelines: clinic attendance, height, weight, baseline Varicella Zoster status (VZS) and Thiopurine Methyltransferase (TPMT) and appropriate plasma monitoring (frequency and actual sample request) of FBC, U and Es, amylase, CRP and LFTs. The Mann Whitney Test was performed to determine if some of the demographic data had any correlation with suboptimal AZA monitoring. A ‘patient factor score’ was generated based on the centre’s compliance with these points, with a score of zero to eleven. A score of less than eleven was considered as substandard monitoring. Results Only 16 patients (19%) had a patient factor score of eleven. Regarding adherence to the recommended frequency of blood monitoring, only 27 (24.5%) patients were fully compliant. 3 patients (2.7%) did not have any of their blood components measured. Although TPMT was measured in 104 patients (97%), in 48 patients (46%) it was measured late. All the 7 patients (6.7%) whose TPMT was low had AZA prescribed at appropriate doses. Weight and height was not documented in 31 (28%) and 47 patients (43%) respectively. Baseline VZS was not checked in 23 (21%) of the patients. Clinic attendance was good, with only 6 (5%) pat[...]



    P13 An evaluation of vitamin d supplementation to babies on the neonatal unit

    2018-01-19T07:28:36-08:00

    Aim In 2014, NICE guidance outlined the recommended amount of vitamin D in newborn infants.1 Such deficiency is associated with rickets, hypocalcaemia and seizures.2 The aim of this study was to determine whether babies on the neonatal unit received the recommended daily amount of vitamin D by comparing national guidance against our local neonatal policy. To assess how babies obtained their source of vitamin D on the neonatal unit. Method Local policy stipulates for pre-term babies<1.8 kg a daily intake of 800–1000 units is recommended and for term babies (>37 weeks) 400 units is recommend. Pre-term and term babies>1.8 kg a dose of 400 units is recommend. Data collected over a 6 week period (1 week pilot study) included prescribed medication, milk volume, milk type (formula or fortifier) and demographics of the patient population. Inclusion criteria: babies with a postnatal age >2 weeks and enteral feeds >120 ml/kg/day. Exclusion criteria: babies with a postnatal age <2 weeks, on TPN, donor breast milk or on demand breast-feeding. Results 30 babies identified of, which 21 were classified as pre term and 9 as term. 100% (9/9) of term babies and (3/3) pre-term babies weighing >1.8 kg received the recommended daily vitamin D intake (either as colecalciferol or abidec). The remaining 18 pre-term babies weighing <1.8 kg; 83% (15/18) received the recommended daily intake (either as colecalciferol, abidec, fortifier or milk formula). Overall, from the 30 babies identified in this study 90% (27/30) received their daily recommended intake of vitamin D. Conclusion This is the first study conducted, which concluded that 90% of babies receiv[...]



    P14 Discord between patients general practitioner repeat prescriptions and the medication list held by a paediatric cf centre

    2018-01-19T07:28:36-08:00

    Aim To audit GP repeat prescription records in comparison with medication lists held in patients’ electronic notes (EMIS) in our centre, to identify any discrepancies and pharmacist interventions. Method Between October 2011 and June 2014, a pharmacist retrospectively reviewed the CF Centre medication lists, and compared them with the patient’s GP repeat prescription (accessed using Summary Care Record), identifying differences in doses, formulation, and directions. In addition, omissions from each list, drug-class duplications, drugs requiring cessation, and dosing errors were noted. The last date of dispensing was used as an indicator of adherence, and where necessary, GPs were contacted for further information. Pharmacist interventions requiring further action were recorded. Results Drugs (n=2009), were reviewed from 232 patient episodes. Total number of pharmacist interventions was 589 (29.3% drugs), with 20 prescribing errors identified as being clinically significant requiring immediate resolution. Dose and formulation discrepancies were noted in 141 (7.0%) and 48 (2.4%) drugs respectively. Omissions occurred on the GP prescription for 73 medications (3.6%), 30 of which were unlicensed. There were 69 (3.4%) omissions on the CF Unit medication list. Common drugs missed off the GP prescriptions were unlicensed medicines (ULM), accounting for 40% of GP omissions. Common drugs missed off the CF Centre drug list were dietary products and ‘acute’ courses (e.g. antifungals, eradication regimens) initiated by the CF Centre. The CF Centre was unaware of some GP prescribing of contraceptives and inhalers. 25 patien[...]



    P15 Melatonin prescribing audit

    2018-01-19T07:28:36-08:00

    Aim To investigate the practice of melatonin prescribing amongst clinicians in outpatient setting and whether the treatment has been reviewed regularly. Method Data was collected from JAC (Pharmacy Computer System) report detailing patients receiving melatonin from pharmacy, cost centre, quantity, date between 1 st Nov 2014 and Oct 2015. Data on in-patient supply were excluded as the focus of the audit was around patients who are on long term treatment and are seen in outpatient clinics or in the community setting. A sample of patients was randomly selected from the list. Details about consultant, clinical indication, whether melatonin was reviewed, date of clinic, other sedatives patients received, type of melatonin prescribed, were recorded by reviewing clinic letters between Nov 2014 and Dec 2015. Results A total of 774 patients received melatonin dispensed from pharmacy on 4 or more occasions between Nov 2014 and Oct 2015. In-patient supplies were excluded. 404 out of 774 patients were audited. The sample size was large enough to represent our overall population. 8% of patients were prescribed Circadin 2 mg tablets; 61% of patients were on a combination of unlicensed immediate release (IR) melatonin 2 mg capsules and Circadin; 31% of patients were on unlicensed IR melatonin 2 mg capsules. 238 (59%) patients attended follow up clinics and had their melatonin reviewed; 81 (20%) patients attended clinics but melatonin review was not documented; 42 (10%) patients who were on long term melatonin had not attended a clinic appointment for over a year and another 39 (10%) patients who were newly initiated on mel[...]



    P16 An audit of domperidone prescribing in children

    2018-01-19T07:28:36-08:00

    Introduction/aim The European Medicines Agency (EMA) reviewed the use of domperidone containing medicines in March 2014, due to concerns about cardiac abnormalities. The Medicines and Healthcare products Regulatory Agency (MHRA) then responded and issued a drug safety update in May 2014,1 which listed new restricted indications, dosing, duration and contraindications for domperidone.In May 2015 the Neonatal and Paediatric Pharmacists Group (NPPG) released a statement on the use of domperidone.2 This was a highly significant document in child health, and empowered paediatric pharmacists to react to national alerts and implement changes locally. The aim of the audit was to collect information on the current prescribing of domperidone in paediatric patients in a hospital setting, and to evaluate the effects of the alerts on prescribing. Method Patients aged 0–18 years were retrospectively identified within a children’s hospital (n=60) as having domperidone prescribed between the 1 st of January 2014 and the 31 st of July 2015 using electronic prescribing records. For each patient, data was collected regarding domperidone dose, indication, duration, monitoring and non-pharmacological interventions for gastro-oesophageal reflux disease (GORD). Results A total of 60 patients were included in the audit, of which 10 (17%) were prescribed domperidone after the publication of the NPPG alert.In terms of dosing, 43/50 (86%) achieved the standard before the NPPG alert; for duration 6/50 (12%), for indication 9/50 (18%); for ECG monitoring in high risk patients 12/33 (36%) and for th[...]



    P17 An audit of enoxaparin prescribing and monitoring in child health

    2018-01-19T07:28:36-08:00

    Background Venous thromboembolism (VTE) is becoming increasingly recognised in children’s healthcare despite being relatively uncommon in comparison to the adult population.1,2 The incomplete haemostatic system that is present at birth responds with different pharmacokinetics and pharmacodynamics to anticoagulation therapy using low molecular weight heparins (LMWHs) in comparison to adults.3 It is not clear from what age adult dosing can be applied however this is thought to be around 16–18 years. Currently no comprehensive local guidelines are available for the prescribing and monitoring of enoxaparin in paediatric patients. Due to the increasing use of enoxaparin, there is a need to develop local guidelines for both prophylaxis and therapeutic treatment. Aim To audit prescribing and monitoring of enoxaparin within the Children’s Hospital prior to the development of comprehensive local guidelines. Method Retrospective and concurrent methods were used to collect data from all paediatric patients prescribed enoxaparin between the 1 st January 2015 and the 31 st January 2016. A range of computer systems, including ePrescribing records, an electronic results server and electronic and paper based notes were used to investigate each patient identified. Data was collected regarding enoxaparin indication, dosing and anti-Xa levels with data being entered into the audit tool. Results 71% (n=17) of therapeutic treatment enoxaparin prescriptions were dosed according to the BNFc with no documentation found to justify alternative dosing regimens. [...]



    P18 An evaluation of paracetamol prescribing across the child health wards to ensure optimal analgesia whilst avoiding toxicity following recent changes to maximum daily doses

    2018-01-19T07:28:36-08:00

    Aims To evaluate paracetamol dosing in paediatric patients against local1 and BNFc2 guidance following advice that toxicity can rarely occur with doses exceeding 75 mg/kg/day. Secondly to determine adherence to regular paracetamol prescriptions to establish the impact of analgesia by reviewing Wong and Baker pain assessment.3 Method The drug charts of all paediatric inpatients on five separate days were retrospectively reviewed to identify patients prescribed paracetamol for analgesia. The drug charts were scrutinised to determine if any doses of paracetamol prescribed potentially exceeded 75 mg/kg/day. The doses, routes, frequencies, and doses in mg/kg of paracetamol prescribed were recorded. The number of regular paracetamol doses administered was compared against the prescribed frequency and the numbers of regular doses omitted with and without documented reason were recorded. The comfort round sheets were reviewed to establish if the Wong and Baker pain assessment3 were used to assess pain and results obtained before and after the first 24 hour period of regular paracetamol treatment were recorded where available. Results 75 paediatric patients prescribed paracetamol for analgesia were identified over data collection period, approximately 50% split surgical: medical. One patient had no dose frequency of paracetamol prescribed hence the data of a total of 74 paediatric patients was analysed. 78% of paediatric patients were prescribed paracetamol for use when required; in surgery 40% were prescribed regular paracetamol comp[...]



    P19 Development of a guideline on management of medicines for patients on a ketogenic diet

    2018-01-19T07:28:36-08:00

    Aim The National Institute for Health and Care Excellence (NICE) states that initiation of a ketogenic diet should be considered for children and young people whose epilepsy has not responded to anti-epileptic drug therapy.1 At present, no guideline exists within the Trust about ketogenic diets and so it was agreed that some guidance would be appropriate to guide doctors, nursing staff and pharmacists about how to manage medication for paediatric patients on a ketogenic diet. Method A literature search was conducted using Embase and Medline with the search terms ‘ketogenic diet’ and ‘epilepsy.’ The only filters included in the search were to ensure information was in English and that human subjects were the focus. Guidance used within other Trusts and recommendations from the International Ketogenic Diet Study group were also considered.There is a paediatric ketogenic dietician within the Trust and so she was consulted for her advice throughout guideline development. Results A guideline has been produced that addresses how medicines should be managed for patients on a ketogenic diet. If any new medicines are initiated within hospital, practical advice is given on how to ensure the carbohydrate content is minimal, and the importance of ensuring ketone levels are monitored. The guideline also briefly considers the acute and chronic effects of the ketogenic diet and how these may result in other medicines and supplements being prescribed. Given that there is no nationally recognis[...]



    P20 Pic study: prednisolone in children: prescribing, dispensing and administering prednisolone formulations to children with acute asthma or wheeze

    2018-01-19T07:28:36-08:00

    Aim To explore the current prescribing, dispensing and administration practice for oral prednisolone to children with acute asthma or wheeze. Method A semi-structured telephone interview following a course of oral prednisolone. The interview questions were designed during consultation with a multidisciplinary team and explored: doses prescribed, formulations prescribed and dispensed, parent/legal guardian/patients’ experiences and perceptions of prednisolone administration and medicines manipulation and adherence. Parents/legal guardians of children aged 2–11 years and young people over 12 years with acute asthma/wheeze prescribed a short course (≤7 days) of oral prednisolone on the Children’s Assessment Unit (CAU) or in the out-patients department were eligible to consent/assent to this study. Ethical approval was granted. Results 20 families completed the study. The ages of children ranged from 2–16 years (average=5 years). Specific formulation details (e.g. tablets, soluble tablets, EC tablets) were provided by prescribers in only 20% of the oral prednisolone prescriptions. There was variability in dispensing soluble versus tablet formulations across child ages; the average ages of children prescribed soluble tablets and non-soluble tablets were 4 years and 11 years respectively. 80% of oral prednisolone formulations dispensed were soluble tablets. In 40% of cases, manipulation techniques were provided by parents to improve patient acceptance o[...]



    3 Pharmaco-stability of plasma-lyte 148 and plasma-lyte 148+5% glucose with commonly used therapeutic agents

    2018-01-19T07:28:36-08:00

    Aims Plasma-Lyte 148 is a balanced, crystalloid intravenous fluid which is both calcium-free and isotonic. It has been demonstrated to reduce the risk of hyperchloraemic metabolic acidosis and iatrogenic hyponatraemia seen with use of normal saline and hypotonic solutions respectively. Investigating the compatibility of Plasma-Lyte 148 and Plasma-Lyte 148+5% gucose with morphine, midazolam, fentanyl, ketamine, clonidine, aminophylline, salbutamol and furosemide will provide vital data to facilitate the introduction of these fluids into routine paediatric practice. Method Chemical stability was assessed by high performance liquid chromatography (HPLC) using the ‘Hewlett Packard (Agilent) 1100’ HPLC system. A gradient method with 20 mM ammonium carbonate (A) and acetonitrile (B) mobile phases and an ‘ACE Excel 3 SuperC18’ column was used. The flow rate was set to 0.03 ml/min, temperature to 40°C and injection volume for all drug admixtures to 5 µL apart from ketamine (4 µL) and furosemide (1 µL). Physical stability was assessed by observation of precipitate formation or colour change. Six repeats of each IV fluid and drug mix were assayed at three time points: 0, 2 and 24 hours. pH changes were measured using Fisherbrand Hydrus 300. Normal saline and 5% glucose were used as controls for all experiments. Results No precipitate formed in any of the samples. Chemical stability was defined as <5% concentr[...]



    P21 The level of compliance with medication reconciliation on discharge for paediatric patients at hospital

    2018-01-19T07:28:36-08:00

    Background Medicines reconciliation (MR) is the process of creating the most accurate list possible of all medications a patient is taking.1 The National Institute of Excellence (NICE) published guidance in 2015 on MR for all care settings which advise health and social care practitioners to proactively share and complete accurate information about medication, ideally within 24 hours of the patient being transferred.2 Objective To determine if NICE guidance for MR and communication on discharge is being followed on the paediatric inpatient wards at this Hospital Standards 100% of discharge summaries (DSUMs) include any known drug allergy status 100% of patients have their medicines accurately reconciled by a pharmacist and/or doctor at discharge 100% of relevant DSUMs include the reason for the stop, start or change to medication 100% of patients have their DSUM sent to the GP within 24 hours of discharge 100% of relevant DSUMs include the appropriate supply information for special/unlicensed medications. Methodology Data was collected retrospectively for 2 weeks on the paediatric wards. Each patient discharged was assessed for eligibility for the audit. The inclusion criteria were: Any patient admitted for ≥24 hour stay in hospital with ≥1 regular medication from the drug history. DSUMs were printed for each patient and a data collection form completed to assess compliance with audit standards using the ele[...]



    P22 Using an elastomeric pump to administer continuous infusions of antibiotics as part of an outpatient parenteral antimicrobial therapy (opat) programme

    2018-01-19T07:28:36-08:00

    Aims Continuous intravenous infusion using an elastomeric pump is an alternative delivery method in paediatric patients who need intravenous antibiotics (IVAB) which would otherwise need to be administered three times daily, such as piperacillin/tazobactam or ceftazidime.1 We describe our experience using elastomeric pumps in the OPAT setting. Methods A retrospective case series of 5 children (aged 5–17 years) discharged home on IVAB continuous infusion administered via an elastomeric pump. One child received this mode of delivery twice therefore 6 patient-episodes are described in this case series. Outcomes were assessed using the BSAC p-OPAT (British Society of Antimicrobial Chemotherapy Paediatric-OPAT) criteria. Ethics approval was not required because the information was gathered retrospectively and patient data has been anonymised. Results In 5 of the episodes the indication was lower respiratory tract infection treated with continuous IV piperacillin/tazobactam. All patients had a background of neurodisability, recurrent respiratory tract infections and Pseudomonas aeruginosa carriage. The remaining patient was treated for an infective exacerbation of cystic fibrosis with a regimen that included continuous IV ceftazidime. All episodes had an outcome defined as ‘Success’ according to the BSAC p-OPAT criteria; having an infection outcome of ‘improved’ or &lsq[...]



    P23 Tolerability of prednisolone and dexamethasone in children in saudi arabia and the united kingdom

    2018-01-19T07:28:36-08:00

    Background Corticosteroids are used to treat conditions including acute asthma and croup where they are often given in short-courses. This study evaluated the tolerability and palatability of oral prednisolone and dexamethasone in children in Saudi Arabia (SA) and the UK. Methods A prospective observational/interview study was performed. Palatability was evaluated by asking patient/parent’s opinions of the taste and acceptability of the medication. Children pointed at the appropriate face on a scale depicting: 1 ‘dislike very much’, 2 ‘dislike a little’, 3 ‘not sure’, 4 ‘like a little’ and 5 ‘like very much’.1 Tolerability, in particular nausea, vomiting and abdominal pain was evaluated by direct questioning of the patient/parents after each administration. Data was collected over three months in each centre. Patients aged 2–18 years treated with oral prednisolone or dexamethasone in hospital were approached to participate. Results In SA, 122 patients (89 asthma, 33 croup), aged 2–10 years (mean=4.3) were recruited: 52 received prednisolone base tablets; 37 prednisolone sodium phosphate syrup; 33 dexamethasone elixir. In the UK, of 133 patients (80 asthma, 53 croup) aged 2–16 years (mean=4.9): 38 received prednisolone base tablets; 42 prednisolone sodium phosphate soluble tablets; 53 [...]