Penny Fletcher

The ‘unified airway’: the RCPCH care pathway for children with asthma and/or rhinitis

Aims The Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies: the asthma/rhinitis care pathway is the third such pathway. Asthma and rhinitis have been considered together. These conditions co-exist commonly, have remarkably similar immuno-pathology and an integrated management approach benefits symptom control. Method The asthma/rhinitis pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The pathway was reviewed by a broad group of stakeholders including the public and was approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. Results The pathway entry points are defined by symptom type and severity at presentation. Acute severe rhinitis and life-threatening asthma are presented as distinct entry routes to the pathway, recognising that initial care of these conditions requires presentation-specific treatments. However, the pathway emphasises that ideal long term care should take account of both conditions in order to achieve maximal improvements in disease control and quality of life. Conclusions The pathway recommends that acute presentations of asthma and/or rhinitis should be treated separately. Where both conditions exist, ongoing management should address the upper and lower airways. The authors recommend that this pathway is implemented locally by a multidisciplinary team (MDT) with a focus on creating networks. The MDT within these networks should work with patients to develop and agree on care plans that are age and culturally appropriate.

Review of commonly used age-based weight estimates for paediatric drug dosing in relation to the pharmacokinetic properties of resuscitation drugs

To study which weight estimate calculation used in paediatric resuscitation results in optimal drug dosing; Advanced Paediatric and Life Support (APLS) or the UK Resuscitation Council age‐based formula.

Drug errors before and after implementation of electronic prescribing on paediatric intensive care unit

Aims To identify the number and type of prescribing errors and dose omissions before and after implementation of electronic prescribing on Carevue (Phillips, UK), an ICU clinical information system, installed in our paediatric intensive care unit (PICU) in February 2009. Methods Prospective audit of prescribing errors and missed doses for 96-h periods in three epochs—before implementation of Carevue (Epoch 1), one week after implementation of Carevue (Epoch 2) and 6 months after implementation of Carevue (Epoch 3). Prescribing errors were further classified as incomplete prescription, insufficient information, illegible prescription, prescribing error and other. The χ2 was used to compare proportions. Results Electronic prescribing on Carevue was associated with a significantly lower incidence of missed doses, likely due to electronic worklists and alerts for nursing staff. There was also a tendency towards a lower incidence of prescribing error, likely due to predefined standard orders for drugs and infusions commonly used on the PICU (figure 1). Incomplete prescription, insufficient information and illegible prescriptions as causes of prescribing error were not seen following implementation of Carevue. Conclusions A clinical information system can significantly reduce the incidence of drug errors in PICU. Abstract G80 Table 1 Epoch 1 Epoch 2 Epoch 3 Prescribing errors (n/number of prescriptions) 14/159 (8.8%) 17/208 (8.1%), ns 12/257 (4.6%), ns Missed dose (n/total doses given) 43/528 (8.1%) 23/216 (10.6%), ns 4/278 (1.4%), p<0.05

AN AUDIT OF THE PAEDIATRIC EMPIRIC ANTI-INFECTIVE GUIDELINES AND ANTI-INFECTIVE DRUG DOSE TABLE FOR CHILDREN

Aim To assess compliance with paediatric empiric anti-infective guidelines and anti-infective drug dose table for children. Method Data collection was carried out on the paediatric wards. Exclusions ▸ Bone marrow transplant patients (BMT). ▸ Patients not on empirical anti-infective treatment Data were collected prospectively between January and 30 February 2015. A data collection form was completed and data analysed using Excel. Standards (1) 90% adherence to the paediatric guidelines for empirical anti-infectives treatment (2) 90% prescriptions have the indication recorded in either the drug charts or notes (3) 90% prescriptions have duration recorded of treatment/review date on drug chart or medical notes (4) 95% initial doses should adhere to the anti-infective drug dose table for children Results Data were collected from 50 patients; eight were subsequently excluded as they were not on empirical treatment or were prescribed antibiotics started prior to admission giving a final sample for analysis of 42. 40/41 prescriptions (98%) adhered to the paediatric guidelines for the empirical treatment prescribed. 1 of 41 prescriptions (2.4%) did not. Exclusion criteria: One indication was not within guidelines (‘abscess’). 40/42 prescriptions (95%) stated the indication for the anti-infective. 2 (5%) required prompting from the pharmacist. 14 out of 42 (33%) had the indication documented in the notes and 28 (67%) on the drug chart. 26/42 prescriptions (62%) had a record of the duration of treatment/review date on the drug chart/notes. Of the 26 prescriptions with a recorded duration of treatment, 2 (8%) were found in the notes and 24 (92%) were found in the drug chart. 67/69 (97%) of the initial doses adhered to the anti-infective drug dose table for children. 2 out of 69 (3%) did not. Conclusions Standard 1 passed, this shows an improvement from the last audit of the guidelines in 2013 (of 72% adherence). In one case the indication of the antibiotic was not within the guidelines, which should be amended. Standard 2 passed—However, most of the indications were found in the notes, with clear documentation space on the drug chart it would be useful to have the indication in the drug chart. There has been a significant improvement from the previous audit carried out (from 16%). Standard 3 did not meet the adherence requirement expected. However, there has been an improvement from 14% from last year. Standard 4 (not been previously audited) suggests that the drug dosing table is also clear in providing guidance. Two data were excluded from the overall data as cefuroxime and rifampicin are not in the guidelines. Overall, the main need for improvement is having the duration of treatment documented. To achieve improvement in all standards would require: ▸ Presenting the results to the antibiotic stewardship and pharmacy team. ▸ Implementing an electronic prescribing system which prompts for completion of essential fields. ▸ Updating and renewing the antibiotic Smart-phone App. ▸ Compulsory education sessions for the junior doctors by the antibiotic stewardship team.

AN AUDIT OF SEDATION PRIOR TO NON-PAINFUL PROCEDURES IN CHILDREN

Aim To audit the quality of sedation prior to procedures and identify reasons for ineffective sedation. Method All paediatric patients (excluding intensive care) at Hospital X receiving pharmacological pre-procedural sedation were included. The sedation guideline had been recently updated but anecdotally the old guideline was being followed due to perceived sedation failures when following the new guideline. Staff nurses and ward pharmacists were asked to refer patients for the audit using a referral form. A poster was displayed in drug treatment rooms and labels attached to sedative medication to remind nurses to refer any suitable patients for the audit. Patients were also identified by looking in the ward diary for scheduled procedures. Data were collected on the day of the procedure, over a period of seven weeks (6th Jan to 21st Feb 2014) using a piloted data collection form. Data were analysed using Microsoft Excel based on drug and dose used, sedation success or failure, and on which guideline was followed. Standards: New guideline followed (Target 90%) Old guideline followed (Target <10%) Correct drug used (Target 100%) Correct dose used (Target 100%) Effective sedation (procedure could take place) (Target 90%) Results: 12 patients were identified and included in the analysis. The new guideline was adhered to in 7/12 (58%) of cases. 11/12 (92%) of patients received the correct drug and 8/12 (75%) received the correct dose according to the new guideline. Effective sedation was achieved on time in 7/12 (58%) of patients. In 3/12 (25%) of cases the procedure was delayed, taking place later the same day following a second dose of chloral hydrate 50 mg/kg. 2/12 (17%) of cases failed sedation and the procedure had to be re-scheduled under general anaesthesia. Four patients were given chloral hydrate 100 mg/kg, all were succesfully sedated. Chloral hydrate 50 mg/kg in combination with alimemazine 2 mg/kg achieved effective sedation in only 1/2 (50%) of patients, however one of the children receiving this combination weighed 16 kg and according to the new guideline should have received midazolam (0.5 mg/kg orally or 0.2–0.4 mg/kg intranasally). The least successful sedative was chloral hydrate at a dose of 50 mg/kg, with only a 1/4 (25%) success rate. This dose does not feature in the new guideline and should therefore never be used as a single agent. Only two patients were given midazolam, one of which (intranasal 0.33 mg/kg) resulted in successful sedation. The other, an oral dose (0.5 mg/kg) failed. Conclusion The sample size was small but chloral hydrate 50 mg/kg appears to be an ineffective dose. Patients <15 kg should be prescribed either 100 mg/kg or co-prescribed chloral hydrate 50 mg/kg and alimemazine 2 mg/kg. Further local data are required regarding the effectiveness of midazolam. The results do not necessitate a change in the current guideline, as procedures carried out according to the guideline were successful in the majority of cases, but rather a change in practice to reflect the guidance. Prescribers need to be made aware of the correct chloral hydrate dose and non-adherence to recommended practice.

AN AUDIT OF THE ACCURACY OF DRUG PRESCRIPTION INFORMATION ON TRANSFER LETTERS FROM THE PAEDIATRIC INTENSIVE CARE UNIT

Aim To audit the accuracy of prescribing following transfer from a Paediatric Intensive Care Unit using electronic prescribing. Methods Historical data: Transfer from PICU letters sent to both external Trusts and wards within the same hospital were randomly selected pre and post the electronic prescribing system upgrade (July 2012) and compared with the final prescription screen of the inpatient electronic prescription record (EPR). Current data: For patients transferred to a ward of the same hospital between 17 December 2012 and 28th January 2013, the first handwritten drug chart after transfer from PICU was also reviewed for accuracy in comparison to the PICU EPR. Audit standard: 100% of patients transferred from PICU have correct transfer from PICU letters with regard to prescribed medicines. 100% of patients transferred from PICU to a ward within the hospital have correct transfer from PICU letters and correct first inpatient drug chart. Results Data were collected for 16 patients pre-upgrade: 6 had correct transfer letters, 10 (63%) had errors. Among the 85 drugs prescribed, there were 12 errors involving 12 drugs (14% of drugs). After the July 2012 upgrade 14 patients were analysed, 10 had correct transfer letters, 4 (29%) had errors. Of the 80 drugs prescribed there were 8 errors (10% of drugs documented in the letters were wrong). Data were collected for 13 patients transferred to wards within the hospital; 9 (69%) had correct transfer letters and a correct first inpatient drug chart. Two patients had errors on their transfer letter and first drug chart, and two had errors on the transfer letter but the drug chart was correct (due to ward pharmacist intervention). There were 6 errors in total for these 4 patients. Errors included incorrect gentamicin and vancomycin doses and incorrect information about whether patients still required morphine, azithromycin and ceftriaxone. Following this audit a meeting was held with senior PICU consultants. The EPR software company have been contacted to improve the automated transfer letter system. Meanwhile the automated transfer letter has been modified to exclude drugs and junior doctors are requested to input this data manually. The signing consultant is reminded to check the prescription section carefully to prevent errors. Discussions are ongoing for nurses to be part of the checking process. Conclusion Transfer letters are not being thoroughly checked before being sent with the patient on transfer from PICU. Some errors were due to a system failure where dose changes were not pulled across to the transfer letter. This did not resolve after the July 2012 upgrade. Errors appear to have reduced over the data collection period however this is anecdotally due to a raised awareness of the system failures and some junior doctors writing their own drug list rather than relying on the system to generate it. In order to meet expected standards of 100% correct information on transfer letters much closer attention must be paid to final accuracy checks.

An Audit of Medicines Reconciliation in Paediatrics

Medication reconciliation (MR) is obtaining an accurate list of medicines prior to admission and ensuring that the current prescription corresponds to this. It occurs at any point of transfer of patient care.1,2 The aim was to collect baseline data on the level of completion of medicines reconciliation for paediatric inpatients by healthcare professionals. Standards3: MR should be documented by the admitting healthcare professional in the patient medical record, within 6 h of admission- 100% Paediatric patients will have a medication history taken by a member of the pharmacy team within 72 h, where necessary- 60%. Where it is clear that there is no previous medical history, a repeat medication history by the pharmacy team is not necessary. 100% of known patients or those with a previous medical history will have a drug history documented within 72 h. 100% of discrepancies identified by the pharmacist have been discussed and rectified with the medical team Method All patients admitted to three medical wards between 5 January 2012 to 19 January 2012 and whose drug chart and notes were available were included in the audit. A pilot was conducted between 5 January 2012 to 6 January 2012. Data were collected after the pharmacist had visited the ward. For each patient, the relevant pages of the drug chart and medical notes were photocopied for quality assurance which was carried out with the project supervisor. Results 44 patients were included in the audit and 70% (n=31) had a drug history taken on admission (either in A&E or on the ward) 97% (n=30) were completed within 6 h 64% (n=28) had MR performed by a pharmacist 100% (n=28) were completed within 72 h of admission. Nine patients had no past medical history thus not requiring pharmacist MR, three patients may have required a repeat MR and four did require a repeat MR. 11% (n=5) had no MR documented by any healthcare professional. 25% (n=7) patients had an intentional or unintentional discrepancy between pre- and post-admission medication. Ten discrepancies were identified with four intentional changes and six were unintentional which were rectified on discussion between the doctor and ward pharmacist. Conclusions Baseline data has been obtained regarding medicines reconciliation in paediatrics. The results have highlighted that doctors are not always documenting MR and pharmacists are not carrying out repeat MR in patients who require one, for example, those with a past medical history, however all discrepancies identified are clarified and when necessary are rectified.