THE SENSITIVITY OF THE PAEDIATRIC TRIAGE TOOL IN IDENTIFYING CARE ISSUES

AIM

The paediatric triage tool was previously developed within the hospital to allow delegation to less experienced pharmacists to provide clinical pharmacist cover and allow identification and prioritisation of patients depending on pharmaceutical care requirement within a paediatric population. The paediatric triage tool triages patients via a traffic light system and identifies patients who are at high risk and who need to be reviewed first each day, rather than trying to see every patient and every drug chart. The traffic light system involves three colours. Red is highest priority and requires daily pharmacy review; amber patients do not require such intensive patient monitoring and so may be reviewed every second day; and green patients require only minimal pharmaceutical input and will not be reviewed again until discharge. The paediatric triage tool was previously implemented over 5 days on the 24 bed medical admissions ward and evaluation of the results revealed that time spent by the ward clinical pharmacist providing a daily review to patients that the triage tool coded green may have been better spent on the patients triaged in to the amber and red categories.This study intended to establish the sensitivity of the paediatric triage tool in identifying care issues as highlighted by an experienced clinical pharmacist. This study looked to highlight any areas of weakness in the tool and allow further optimisation and was agreed that the paediatric triage tool should identify 90% of care issues as identified by the experienced clinical pharmacist.

METHOD

The experienced clinical pharmacist was based on the 24 bed medical admission ward during the week of the study and all patients were followed up with normal pharmaceutical care; each episode requiring pharmacist action, defined as a care issue. Independent of the clinical pharmacist patients were also seen by myself during the week using the paediatric triage tool. Application of the tool was compared to the prioritisation by an experienced clinical pharmacist independent of the tool. The number of care issues identified was used to determine if the tool was sensitive in identifying care issues.

RESULTS

Initial results of the study showed a lot of potential in applying the tool including reducing bed monitoring days for some patients and allowing increased clinical pharmacy input into higher risk patient. However results revealed the paediatric triage tool was sensitive in picking up 87% of care issues as identified by the experienced clinical pharmacist and therefore did not meet the audit standard of 90% as five care issues were highlighted by the experienced pharmacist but missed by the tool. The five care issues that were missed by the paediatric triage tool were looked at and it was observed that the care issues identified was due to acquiring suitable dosage forms and preparations.

CONCLUSION

The paediatric triage tool showed a high sensitivity in identifying care issues, paediatric care issues such as acquiring suitable dosage forms and preparations were added to the triage tool and we plan to readuit to achieve the 90% standard as initially set.

DOES MORE SPECIALIST PHARMACIST TIME IN A CLINICAL AREA EQUAL MORE ACTIVITY?

BACKGROUND

Following a medication safety initiative proposed by the PICU Safety Strategy group a pilot was set up to extend the presence of a PICU trained pharmacist in the clinical area.One of the main safety initiatives was to assess whether increased pharmacist exposure decreased drug omission of time critical medicines, which was highlighted from incident reporting patterns on PICU.

AIM

To assess what impact extending a pharmacist with specific PICU training would have on the medicines management of the PICU patients.

METHOD

The pilot involved attendance on the afternoon ward round, review of all new admissions and follow up of priority patients as highlighted by the "day" PICU pharmacists. The pilot "late" PICU pharmacist was resident in the hospital, on PICU, for an hour longer than the pharmacy opening hours. A rota ofA basic data collection form was set up on Microsoft Excel. Data collected included start and finish times of the ward round, time leaving PICU, clinical interventions made, queries by staff on PICU and outside of PICU, supplies made, drug omissions prevented, number of times the presence on the unit prevented need to call in the on call pharmacist and interpretation of drug assays reported after pharmacy hours. Follow up of specific medicines management issues highlighted by the "day" pharmacists as requiring action prior to following day pharmacy visit were recorded.

RESULTS

During the 74 days data were collected there was 395 drug related queries by PICU staff (252 by nursing staff, 143 by prescribers). The "late" PICU pharmacist was contacted for advice regarding non-PICU patients by the on call or dispensary pharmacist on 7 occasions and 11 times from clinical staff outside of PICU.The "late" pharmacist intervened on 412 prescriptions, some of the interventions arose from the 260 follow up reviews requested by the "day" pharmacists. Of the 236 drug assays reported after pharmacy hours, 126 required intervention by pharmacist.Omission of time critical medicines was prevented on 17 occasions following 79 supplies of non-stock medicines. Calling out the on-call pharmacist was circumvented 11 times.

CONCLUSION

The Safety Strategy teams' request for increased access to a "late" PICU pharmacist resulted in a number of clinical interventions, appropriate dosing advice on late-in-day reported drugs assays and prevention of delays in medicines, including time critical drugs. Benefits of the specialist pharmacist being on-site to the pharmacy service included less need to access the on call pharmacist for either advice or supplies of medicines. During a pharmacy 7 day working review these data were used to secure the increased clinical pharmacy service to PICU.

SERVICE EVALUATION OF A CYSTIC FIBROSIS HOME INTRAVENOUS ANTIBIOTIC SERVICE PROVIDED BY A NHS FOUNDATION TRUST

AIM

To evaluate carers' satisfaction with the current service for home reconstitution and administration of intravenous (IV) antibiotics to cystic fibrosis (CF) patients and identify ways of improving this service to reduce treatment burden.

METHODS

A formative evaluation was conducted of all 17 carers who reconstituted and administered the IV antibiotics at home. This was carried out using a cross-sectional survey. A questionnaire of open and closed questions was sent first class with a pre-paid return envelope to the carers. This was followed by a reminder letter after the set return date.

RESULTS

Thirteen carers responded giving a response rate of 76.5%. The carers had a mean of 2 children in the household with all having 1 child under the care of the paediatric CF team. They had been receiving IV antibiotics for a mean of 8 years and 7 months and had been administering them at home for a mean of 6 years and 1 month. The majority had administered the antibiotics in the last 3 months.Over half received their drugs from the hospital pharmacy, but one carer highlighted that they did not always receive a full supply of the treatment.Removing the reconstitution step by providing pre-prepared syringes could reduce treatment time by around 18 minutes. Overall this could mean a daily reduction in treatment time of almost two hours for a patient who is on two antibiotics three times a day. The majority of respondents stated that they would prefer pre-filled syringes.The carers felt that they received enough training and felt confident in reconstituting and administering the antibiotics. The majority felt that they should receive regular updates to their training and it was highlighted that they are reassessed at the start of each course. Most of the carers felt that they had an opportunity to discuss the IV antibiotics in the out-patient clinic with the doctors and the nurses but none of them would contact the pharmacist. They felt that they were appropriately contacted in advance to organise when the course would start and a proportion were contacting the nurses in advance to organise the treatment around their commitments. When they receive the antibiotics and sundries from the hospital pharmacy they are supplied with written directions for reconstitution and administration. However, the carers did not find these easy to understand. It was highlighted by one that they could not access advice at night.Overall the carers had a high level of satisfaction with the service. Some felt that it could be improved by easier access to advice, having blood tests done by community nurses and pre-filled syringes.

CONCLUSION

Overall this cohort is satisfied with their current home IV service. Improvements could be made by: ensuring carers always receive 100% of all necessary supplies; better access to advice; easier to understand written information; access to blood tests in community; increased awareness of the pharmacist. The majority of carers would like pre-prepared syringes and these could greatly decrease the treatment time.

EVALUATION OF AN ELECTRONIC PAEDIATRIC INTENSIVE CARE UNIT (PICU) MEDICATION RECONCILIATION (MR) FORM

AIM

To gather opinions from doctors and pharmacists to improve the design of the PICU MR form generated by the electronic prescribing and clinical notes system to support transfer of care from PICU to downstream wards that use paper systems.

METHOD

A purposive sample of 10 forms covering a comprehensive range of medication information common to PICU patients was selected from practice between March 2014 and May 2014. Pharmacists (n=7) and doctors (n=9) who received these forms on downstream wards were invited to participate in semi-structured one-to-one interviews (n=20) with the PICU pharmacist within 48 hrs of receipt to explore their views about the form. The interview schedule was informed from literature and peer review. Comments and suggestions about layout and the MR process were invited. Two pilot interviews (1 pharmacist, 1 doctor) were conducted to test a priori themes were covered and that the questioning style was open, avoided leading and the participant was given time to consider their response. Interviews were recorded using an encrypted digital recorder, transcribed and checked (10%) for accuracy and coding. Framework analysis focused on documentation and work processes.

SETTING

A 110 bed paediatric hospital with critical care, medical, neurology, haematology, oncology and mixed speciality surgical services. The 8-bedded PICU uses the electronic clinical information system (CIS) MetaVision® provided by iMDsoft® and includes electronic prescribing and clinical notes. Downstream wards using paper systems are provided with a new paper drug chart and printed CIS documentation on transfer.

KEY FINDINGS

New themes extracted during analysis included misunderstanding of the purpose of the form, barriers to use and accessibility of the form. Despite positive comments about the form "…just pull the sheet and you know the medication is confirmed…" (Pharmacist) and "…I think it's a really good system. I think it's quite user friendly and it prints it out in an easy to read way…" (Dr). Issues were identified including unfamiliar documentation "on a paper kardex you would see straight away [medication was discontinued]… you don't know that you need to look somewhere else until you've missed it and it's along with some other chart…" (Pharmacist). Suggestions were made to alter the layout of the form to follow the logical order of steps in the MR process. Non-standard terminology introduced by the computer system was considered ambiguous. Barriers to using the form included misunderstandings in relation to the stage of the patient's journey - was it referring to admission to hospital, admission to PICU, during PICU admission or transfer from PICU? Educational needs were identified during the interviews. Missing forms were a problem. "…our biggest issue is that they come down without having had the discharge printed off…" (Dr).

CONCLUSION

User input informed recommendations for improvements such as clarity of wording and layout of the form, ensuring the MR form is available downstream and highlighted areas for user education. Further evaluation will be undertaken following implementation of these changes.

A STABILITY STUDY OF OMEPRAZOLE DILUTED IN SODIUM CHLORIDE FOR INTRAVENOUS INFUSION AND DISCUSSION REGARDING CURRENT PRACTICE IN UK PAEDIATRIC INTENSIVE CARE UNITS

BACKGROUND

Omeprazole by intravenous infusion is occasionally warranted in children during episodes of acute upper gastro-intestinal bleeding. This is to ensure the continued suppression of stomach acid to reduce the of risk of re-bleeding.Current practice in UK paediatric intensive care units varies, but the use of 160 mg/1.73 m(3) over 24 hour has previously been reported.1 This is commonly prepared as a 0.8 mg/ml solution changed either at 12 or 24 hrs after preparation depending on reference source used.2 (-) 3 The current practice of using a 0.8 mg/ml (40 mg/50 ml) is off label and not endorsed by manufacturers who recommend a maximum concentration of 0.4 mg/ml3.Following these recommendations would lead to a fluid load of 400 ml/1.73 m(2) which is likely to be significant. Excess fluid intake has been shown to correlate with increased oxygenation index and increased PICU stay.4 The aim of this study is to provide stability data for using 0.8 mg/ml for intravenous infusion which is currently in widespread despite use a lack of published lack of data in this area.

METHODS

A series of analytical techniques were performed to assess physical and chemical stability. Test solutions were prepared by reconstituting Losec® (Omeprazole) 40 mg powder for infusion and diluting to either 50 ml or 100 ml in 0.9% sodium chloride.Reverse phase HPLC analysis was conducted at 0 hrs, 10 hrs and 24 hrs. Particle size was assessed using a zeta potential analyser at 15-minute intervals over 60 minutes.

RESULTS

At both 40 mg/50 mL and 40 mg/100 mL the concentration of omeprazole remained at 101% and 100% after 10 hrs respectively. However significant degradation was seen at 24 hrs as concentrations reduced to 60% and 55% respectively.The difference between degradation after 10 hrs was not statistically significant when samples were compared using paired t-test with t(1)=1.25, p=0.427.Particle size analysis showed no statistical different between amount of particles in samples taken from all time points for both solutions with unpaired t-test t(8)=0.5625, p=0.59.

DISCUSSION

Our study confirmed the current manufacturers recommendations that omeprazole at 0.4 mg/ml is stable in sodium chloride for 12 hrs only. We also showed that a more concentrated solution of 0.8 mg/ml had the same degradation profile as 0.4 mg/ml.We recommend that when continuous intravenous infusions of omeprazole is required, that it is administered by preparing 0.8 mg/ml in NaCl 0.9% and changed every 12 hrs.

PN FOR CHILDREN - INFORMATION LEAFLET

AIM

To produce a leaflet for parents and carers of children receiving parenteral nutrition (PN) explaining:▸ What PN is▸ Why it is given▸ How it will be given▸ Risks & Complications▸ Other useful information▸ Nutrition team contact informationCurrent practice is for the nutrition team pharmacist to give a verbal account of the above information to parents/carers. It was felt that providing this information in a written format would introduce consisitency and allow parents/carers more time to take information on board.

METHOD

An internet search and discussions with other organisations with paediatric gastroenterology specialists was conduted to see if something similar was in existence. A similar information leaflet to what we hoped to produce was not found. Members of the paediatric nutrition team, which included consultants, nurse specialists, pharmacist and dietician, provided input to the type of information that should be included in the information leaflet. A first draft of the leaflet was produced and shown to the parents of current paediatric PN inpatients. Feedback was received and the leaflet updated following consultation with the nutrition team.

CONCLUSION

Production of a very useful information leaflet for parents/carers, containing all the relevant information and detail. The leaflet uses colour and pictures to aid the transfer of information and makes it more attractive to read. The pharmacist is the main point of contact for the paediatric nutrition team and will be the individual responsible for distributing them.

INTER-INDIVIDUAL VARIATION IN THEOPHYLLINE CLEARANCE IN CHILDREN

BACKGROUND

Inter-individual variation in pharmacokinetics in children is an area where there has been little research. We wished to determine the extent of inter-individual variation in the clearance of theophylline in paediatric patients of different ages.

METHODS

A systematic literature review was performed using the following databases; Embase (1974 to January 2013), Medline (1946 to January 2013), CINAHL (1937 to January 2013), International Pharmaceutical Abstracts (1970 to January 2013) and the Cochrane Library. From the papers, the range in plasma clearance and the coefficient of variation (CV) in plasma clearance were determined.

RESULTS

A total of 56 articles reporting on 1,315 patients met our inclusion criteria. Twenty six studies gave individual data. The majority of the studies were in critically ill patients. Inter-individual variation was a major problem in all age groups. The CV was 9-93% in preterm neonates, 20-97% in term neonates, 18-52% in infants, 2-72% in children and 4.5-43% in adolescents. The mean clearance was higher in children (0.85 to 2 ml/min/kg) than in neonates (0.24 to 0.6 ml/min/kg).

CONCLUSIONS

Large inter-individual variation was seen, especially in critically ill patients. Inter-individual variation was higher in neonates than children and adolescents.

A STUDY OF THE EFFECT OF HYPOTONIC HYPER-HYDRATION FLUIDS ON SODIUM BALANCE IN PAEDIATRIC HAEMATOLOGY/ONCOLOGY PATIENTS RECEIVING CHEMOTHERAPY

AIMS

To determine the effect, if any, that hyper-hydration with hypotonic fluids has on sodium balance in paediatric haematology/oncology patients receiving cytotoxic chemotherapy treatment for malignancies.

METHODS

A literature review was carried out and a snapshot of current practice across paediatric haematology/oncology centres in the UK was obtained. A prospective study was carried out in a tertiary paediatric haematology/oncology centre. A total of 98 patient episodes involved hyper-hydration with isotonic 0.9% NaCl, almost isotonic 0.45% NaCl+2.5% glucose with added sodium bicarbonate or hypotonic 0.45% NaCl+2.5% glucose. Serum sodium was monitored before and during hyper-hydration. Results were analysed according to whether children experienced a drop in serum sodium.

RESULTS

Patients who were hyper-hydrated with hypotonic 0.45% NaCl & 2.5% Glucose experienced the greatest mean drop in serum sodium. The mean drop in sodium was 2.11 mmol/L in the group receiving the hypotonic 0.45% NaCl & 2.5% Glucose compared to 0.47 mmol/L in the group who received isotonic 0.9% NaCl or 0.45% NaCl & 2.5% Glucose with added sodium bicarbonate. During the course of the study five patients who received 0.45% NaCl & 2.5% Glucose dropped their sodium to 130 mmol/L or less constituting hyponatraemia. No patient dropped their serum sodium to 130 mmol/L or less in the other two groups. During the course of the study no patient experienced clinical manifestations of hyponatraemia. No child became hypernatraemic.

CONCLUSIONS

In paediatric haematology/oncology patients receiving hyper-hydration with concurrent chemotherapy isotonic fluids are preferable.

CHILDREN'S WARFARIN CLINIC-AN AUDIT OF THE NEW PHARMACIST-LED TELEPHONE SERVICE BASED ON A UNIQUE COMPUTERISED SYSTEM COMPARED TO THE WARD BASED PAPER SYSTEM

AIMS

To audit the new pharmacist-led telephone service for warfarin dosing and monitoring of INR, and compare it to the previous system. The previous system was based on the paediatric cardiology ward, dosing by junior medical staff to dose and documented on a paper system. Also to audit the parent satisfaction of the new system.

METHODS

Search the computerised system to reveal 73 patients on warfarin with a total of 1547 INRs, and looked for any complications or out of range results. This to be compared to a previous audit of the original system of 44 patients on warfarin with a total of 1289 INRs.For parent/carer satisfaction, a questionnaire was sent to parents/carers of all patients who were under the care of the pharmacist-led children's warfarin clinic.

RESULTS

The pharmacist-led children's warfarin service was fully compliant for NPSA safety standards for warfarin dosing. There was no significant difference in the safety indicators from the original service and the pharmacist-led service.11 patients (25%) were lost to follow up from the original service, compared to none in the pharmacist-led service. No patients from either service had an inappropriate target INR and every patient had been given the correct information. 38 out of 53 (72%) parents/carers returned the satisfaction survey. 28 (78%) reported that their overall experience of the clinic was excellent and the rest found it satisfactory.

DISCUSSION

Changing to the pharmacist-led service has meant that it is now compliant with NPSA standards and the safety indicators are comparable to the original service. The service has generally been very well received, with all parents/carers finding the service at least satisfactory and 78% found it excellent. The pharmacist-led service is unique, as it uses a computerised system for documentation, with the aim to produce a paediatric dosing algorithm.

MEDICINES RECONCILIATION FOR PAEDIATRIC PATIENTS ON ADMISSION AND DISCHARGE

INTRODUCTION

National guidance from National Institute for Health and Clinical Excellence (NICE), National Patient Safety Agency (NPSA), World Health Organization and the Royal Pharmaceutical Society has long highlighted the importance of accurate and timely medicines reconciliation (MR) in reducing medication errors for patients upon transfer of care setting.1 (-) 4 Current guidance for MR excludes children <16 years of age, where widespread use of off-label and unlicensed formulations puts this group of patients at a higher risk.

AIM

To quantitatively assess the level of MR for paediatric inpatients on admission and discharge and to ascertain whether Discharge Summary (DSUM) information is sent to the GP in a timely manner.

METHOD

▸ Data was collected retrospectively over a two week period for paediatric take home prescriptions.▸ An electronic prescribing system was used to complete a data collection form, documenting their MR process and timeframe on admission and discharge.▸ The information was recorded onto an online template of the data collection form using Qualtrics software to prepare a Microsoft Excel file for data analysis.

RESULTS

65 paediatric patients on four wards were audited.▸ Standard 1: 32/65 (49.2%) of patients had their drug history (DH) documented within 24 hrs of admission.▸ Standard 2: 39/65 (60.0%) of patients had their medicines reconciled by a pharmacist within 72 hrs of admission.▸ Standard 3: 46/65 (70.8%) of patients had their medicines reconciled by a pharmacist and/or doctor at discharge.▸ Standard 4: 57/65 (87.7%) of patients had their DSUM sent to the GP within 24 hrs of discharge.

CONCLUSION

None of the four standards were met, emphasising the need to develop better MR practice. The following conclusions were identified:▸ A need for more MMTs at ward level to conduct accurate DHs within a timely manner.▸ MR on admission and discharge suffers out-of-hours (OOH), thus supporting plans for seven-day working.▸ A combined effort between different members of the multidisciplinary team is paramount to ensure accurate MR.▸ Doctors need to have the resources available OOH to allow them to prioritise completion of DSUMs in a timely manner to optimise accurate MR communication with GPs.▸ It is evident that anecdotally MR is done to a higher level; however a possible lack of pharmacist understanding on the MR process and its documentation may have contributed to this audit's standards not being met.

APPLICATION OF PHARMACEUTICAL KNOWLEDGE TO THE UNCONVENTIONAL USE OF A RARELY USED ANAESTHETIC AGENT

CASE SUMMARY

A 6 yr old 45 kg child with severe Cushinoid features was admitted to PICU with probable hypertensive encephalopathy. She presented with increasing headaches, vomiting and seizures becoming unresponsive with a GCS of 3. She was profoundly hypertensive and her cortisol levels were significantly elevated (>2000 nmol/L). Rapid reduction in cortisol levels was required to stabilise her condition prior to surgery. Etomidate is the only readily available intravenous preparation which reliably suppresses adrenocortical function. A continuous infusion was started at 2.5 mg/hr and escalated to 3.5 mg/hr to reduce cortisol levels to 200 nmol/L. Cortisol levels were monitored after 1, 2, 4, 8, 12 and 24 hr on starting and at regular intervals subsequently. Hydrocortisone 20 mg/m2/24 hr was introduced to balance the adrenal suppression and optimise cortisol levels to 200-800 nmol/L. Mineralocorticoid replacement with fludrocortisone became necessary, together with significant electrolyte replacement therapy. Surgery was delayed due to sepsis, and block and replace therapy was continued for a period of 3 weeks. During this time she experienced minimal sedative effects from the etomidate.

PHARMACY CONTRIBUTION

Advice was given on the potential toxicity of pharmaceutical excipients. The aqueous formulation of etomidate contains propylene glycol and prolonged infusion can result in significant intake. Calculations revealed an intake of 350 mg/kg/day for this child with an infusion of 2.5 mg/hr etomidate. The WHO limit is 25 mg/kg/day when propylene glycol is used as a food additive.1 An acceptable limit for intravenous exposure has not been established. Children under 4 years have limited ability to metabolise propylene glycol and accumulation can occur. Potential toxicity includes hyperosmolality, metabolic acidosis, nephrotoxicity, arrhythmias and CNS toxicity. To obviate these risks, the alternative lipid formulation of etomidate was obtained. Blood samples were subsequently reported to be lipaemic and concerns were raised about the lipid load of this formulation. Calculations revealed that 0.3-0.5 g/kg/day lipid was being infused, which is significantly less than parenteral nutrition would provide. It is possible that blood samples were withdrawn from the line infusing etomidate resulting in lipaemia, but it is also likely that hypertriglyceridaemia was a result of her underlying condition.The pharmacist was involved in many other aspects of this child's care including advice on intravenous access, infusion preparation, drug compatibility and stability issues, electrolyte management and dosing of various drugs in obesity.

OUTCOME

An ACTH secreting thymic tumour was resected. Hydrocortisone doses were adjusted perioperatively to cover the stress of surgery, and subsequently weaned post-operatively. Complete resection was not achieved and further block and replace therapy was used prior to bilateral adrenalectomy, followed by chemotherapy and radiotherapy.

LESSONS TO BE LEARNT

Pharmacists should evaluate the potential toxicity of excipients in medication, particularly when formulations are given by an unlicensed method of administration in children. Other parenteral products with a significant propylene glycol load include lorazepam, phenobarbital, phenytoin and co-trimoxazole.

ASSESSING THE IMPACT OF A NEWLY INTRODUCED ELECTRONIC PRESCRIBING SYSTEM ACROSS A PAEDIATRIC DEPARTMENT - LESSONS LEARNED

AIM

Prescribing audits have shown that the Women's and Children's Directorate reported higher number of prescription errors on the paediatric and neonatal wards compared to other areas in the Trust. Over the last three years a multidisciplinary prescribing team (PT), which included senior clinicians, pharmacists and trainees introduced a number of initiatives to improve the quality of prescribing. Strategies included structured departmental inductions, setting up of designated prescribing areas and reviewing errors with the prescriber. Year on year there were fewer prescribing errors.1 With the introduction of a new electronic prescribing system in October 2014 prescribing error rates were expected to decrease further, eradicating omissions around allergy recording, ward location and drug names. The aim of this abstract is to highlight the impact of the new system and describe lessons learned.

METHOD

In the summer of 2014, all inpatient drug charts across the department were reviewed on three non-consecutive days over a period of three weeks. Prescribing errors were identified by the ward pharmacist. Errors were grouped according to type and further analyzed by the PT. Errors deemed to have no clinical significance were excluded. Error rates were compared to the previous audits performed with identical methodology. Following the introduction of the electronic prescribing system, the ward pharmacists continued to review prescription charts on daily basis and generate regular error reports to notify the staff of new challenges.

RESULTS

There were 174 (14%) errors out of 1225 prescriptions on 181 drug charts. The most commonly made mistakes included drug name errors, strength of preparation, allergies and ward documentation, prescriber's signature omissions, and antibiotic review and end dates. The introduction of an electronic system has eliminated drug name, strength of preparation, allergy recording and ward errors. However, serious challenges have been identified: entering of an incorrect weight resulted in all drug dosages being inaccurate; the timing of drug levels for Vancomycin and Gentamicin and the administration of subsequent doses have been problematic. Communication difficulties between all staff groups has led to dosage omission, duplicate administration and confusion around start and stop dates. The ability to prescribe away from the bedside and indeed the ward has compounded some of these problems.

CONCLUSION

The implementation of a new electronic system has reduced prescribing errors but has also resulted in new challenges, some with significant patient safety implications. The lessons learned and good practice introduced following previous audits of "traditional paper based" prescribing are equally important with electronic prescribing. Communication between staff groups is crucial. It is likely that the full benefits of the system will be realized a year after its introduction. On-going audit is required to assess the impact and safety of the electronic prescribing and lessons learned.

MELATONIN - WORKING IN COLLABERATION WITH THE CCG TO REDUCE COSTS

AIM

To reduce the overall expenditure on melatonin for the local health economy by working collaboratively with the CCG's. To ensure that all paediatric patients prescribed melatonin have been clinically assessed by a specialist and the most appropriate formulation is dispensed.

METHOD

Evaluation of GP melatonin prescribing cost across CCG using ePACT data and extrapolation of equivalent cost of prescribing and dispensing within secondary care. This initial data was then refined to exclude patients 16 years and over on unlicensed formulations of melatonin and all patients on licensed formulations. This was used to estimate the net potential saving achieved by repatriating the prescribing of melatonin for children for the local CCG's. A six month pilot was initiated to establish if the predicted savings translated into reality for the local health economy.

RESULTS

It was estimated that approximately 100 patients under 16 years were prescribed melatonin by GP's in the local CCG's, 60 of these patients were on unlicensed formulations hence eligible for the pilot. To date we have received 42 referrals from GP's to review the prescribing of melatonin unlicensed formulations. 32 patients had been initiated melatonin by the child development team or paediatric specialist 16 (50%) of whom were currently under the care of the team and being reviewed every six months. 10 of the referrals were for patients under the care of CAMHs who were happy to provide ongoing treatment to avoid duplicated appointments. From the remainder of the referrals 6 patients when contacted had advised that they were no longer using melatonin. The remaining 10 patients have an appointment to review treatment and if deemed appropriate provide ongoing prescriptions using formulations approved by pharmacy. There are still 18 patients prescribed melatonin by Gp's who have not been referred and the medicines management team are chasing. A review of ePACT data for the CCG at the end of the six month pilot compared with the recharge expenditure demonstrated that the predicted net cost of the repatriation was cost neutral for the CCG whilst delivering a predicted saving for the hospital of around £30,000 per annum. Additional savings for the CCG are anticipated once the remainder of the patients are repatriated.

CONCLUSIONS

The initial assumption that all unlicensed melatonin prescribing within the local CCG's was for children with severe learning difficulties was unfounded with a number of GP's prescribing these formulations for adults. Consequently the initial projected savings were an overestimate as only paediatric patients would be repatriated as part of this proposal.The hospital expenditure on melatonin had also increased from the original projections due to increasing patient numbers with GP's unwilling to take on the ongoing prescribing. In addition the child development team had started to use Circadin off label for older patients ensuring cost containment for GP's when patients discharged from the child health team.Despite these barriers to success the overall impact of the repatriation process was cost neutral for the CCG.

MEDICATION MANAGEMENT OF THE EXTREMELY PREMATURE NEONATE - THE IMPACT OF A SPECIALIST PHARMACIST

AIM

To present a case of an extremely premature infant and the role that the specialist neonatal pharmacist has on the quality of care of these patients.

METHOD

Interventions and recommendations made by the pharmacists over the admission of a triplet born at 23 weeks and 5 days gestation were recorded. The type of interventions were categorised and classified for risk using a consequence/probability matrix.1 RESULTS: The patient required admission to the intensive care unit and subsequently the special care unit for a period of 163 days before discharge home. Over the period of admission the patient had a history of a large patent ductus arteriosus, pulmonary hypertension, bilateral grade two intraventricular haemorrhages, neonatal jaundice, hyponatraemia, hyperglycaemia, anaemia of prematurity, retinopathy of prematurity and chronic neonatal lung disease. A pleural effusion developed at day 10 requiring high frequency ventilation. At the age of 3 weeks a pseudomonas sepsis developed together with feed intolerance and abdominal distention. Milk curd syndrome was diagnosed requiring the removal of 30 cm of bowel and placement of a temporary stoma. Long term Parenteral Nutrition was prescribedSixteen interventions were recorded - low risk (3), moderate risk (9) and high risk (4).Clinical advice was provided regarding appropriate dose, therapeutic drug monitoring and administration of antibiotics including gentamicin, meropenem and flucloxacillin to enhance safety and improve efficacy. Owing to the complexity of the medication regimen at times, drug compatibility queries were common. Close liaison with the neonatal consultant, dietician and gastroenterologists was undertaken during long term Parenteral Nutrition and included discussions relating to, administration of additional electrolytes, trace elements and liver function tests. Advice was sought on the dose and administration of loperamide for short gut syndrome and control of diarrhoea. Pharmaceutical advice was provided to ensure medications were optimised for issues associated with drug administration via transpyloric tube to avoid blockage. Calculation of total daily phosphate was undertaken whilst the patient was receiving fortified feeds, to ensure adequate supplementation, to assist normal bone development. Prior to discharge palivizumab prophylaxis was recommended for respiratory syncytial virus Infection. The pharmacist provided advice on administration to the nursing staff and ensured required documentation was completed.

CONCLUSION

The care of the extremely premature neonate involves numerous medication related challenges. This case not only demonstrates the specialist knowledge, skills and attitudes required by a pharmacist working in this complex field but the impact that can be achieved working closely with the neonatal team.

OPINIONS OF USERS OF PHARMACY SERVICE PROVIDED TO PICU

BACKGROUND

Pressures to open pharmacy services 7 days a week, with no financial input for these extra resources, has knock on effects that may dilute accessibility to clinical pharmacists in specialist areas.

AIMS

The aim of this survey was to assess opinions of the users of the current pharmacy services to PICU and the planned extended hours provision.

METHOD

An e-survey was sent to PIC Consultants, Advanced Nurse Practitioners, and Senior Nursing Staff following a six month period of increased clinical pharmacists time allocation to PIC. Free-text area was added to each multiple choice question.

RESULTS

Twenty-four staff responded, 14 prescribers and 10 senior nursesPresence of PICU trained clinical pharmacist on morning ward rounds was considered essential by 19 (79%) respondents and desirable by 4 (17%). Attendance on the afternoon round was deemed essential by 14 (59%) and desirable by 8 (33%) of respondents.Comments on the benefits of pharmacists on ward rounds included:"Enabling a second professional review of the patient overall-it prevents forced direction from the consultant and the pharmacists are empowered to ask us to reconsider. Very useful to have this safety and reality check.""Essential for the guidance of drug usage and drug chart review which improves safety, benefit of advice for use with specialist patients, best cost approach, multiple benefits."Roles expected as routine from the clinical pharmacist included patient safety (100%), managing parenteral nutrition (80%), advice on intravenous therapy e.g. compatibility (100%), education of the multidisciplinary team (96%), management of long term medicines e.g. sedation withdrawal (83%), and therapeutic drug monitoring control (83%).Only 6 respondents felt the PICU patient would benefit from extending access to dispensary only over weekends, 11 felt that there was no benefit, and 6 respondent unsure.Provision of the pharmacy on call service which involves both supply and clinical advice, was felt sufficient to the requirements of the PICU patient by less than a third of repondents,56% feeling the current service insufficient. Comments on the on call service included."difficult to get experienced advice on weekends""need access to pic pharmacists officially.""we may direct queries to the on call pharmacy staff but 9 times out of 10 theses queries are redirected to our PICU pharmacists. Our questions are answered at any time of the weekend"Ninety one percent answered positively to the final question asked about extending the current clinical pharmacy service from 5 to 7 days per week. Comments included."PICU is a 24 hr, 7 day a week service…how we can provide adequate care to children if this valuable service is only provided 5 days a week."

CONCLUSION

Pharmacy is a valued service on PICU, where the service users support increased access and attendance on certain ward rounds by specifically PICU trained pharmacist.

EFFECT OF PASTEURISATION ON THE CONCENTRATIONS OF VITAMIN D COMPOUNDS IN DONOR BREAST MILK

AIM

Breastmilk is considered the most important nutrient and source of supplementation for both term and preterm infants.1 It is composed of many important nutrients, including vitamin D.2 The content of this vitamin in breast milk is usually low, even for lactating mothers with adequate vitamin D status.2 3 Preterm infants are at the great risk of vitamin D deficiency due to decreased transplacental transfer.4 Premature infants are the main recipients of pasteurised donor human milk (PDHM), when their mothers are unable to provide their own.This study aims to evaluate the effect of pasteurisation on the concentrations of vitamin D compounds in donor breast milk.

METHOD

A total of 16 participants, who donated breast milk to the RBWH milk bank, were recruited in this study. Milk samples were obtained pre- and post-Holder pasteurisation. Liquid chromatography tandem mass spectrometry (LC-MS/MS) was used to analyse the samples for vitamins D2 and D3 and 25-hydroxyvitamins D2 and D3 (25(OH)D2 and 25(OH)D3). The significance of differences in vitamin D concentrations between the two groups of milk samples was assessed using the Wilcoxon matched-pairs signed rank test, in which P<0.05 was considered significant.

RESULTS

Pasteurisation resulted in a significant reduction (P<0.05) in the content of D2, D3, 25(OH)D2 and 25(OH)D3, with P values of 0.0001 for all targeted analytes. The concentrations of the vitamin D analogues in non-pasteurised milk ranged from 3.6 to 5.0 pM (D2), 1.0 to 9.8 pM (D3), 1.4 to 2.1 pM (25(OH)D2) and 1.2 to 9.3 pM (25(OH)D3). The concentrations of the vitamin D analogues in post-pasteurised milk ranged from 3.0 to 4.0 pM (D2), 0.6 to 9.5 pM (D3), 1.2 to 1.7 pM (25(OH)D2) and 1.1 to 9.1 pM (25(OH)D3). Losses of vitamin D compounds resulting from the pasteurisation process ranged from 10% to 20%.

CONCLUSION

Pasteurisation significantly affected the concentration of vitamin D compounds in pasteurised donor breast milk.

AUDIT OF PARACETAMOL PRESCRIPTIONS IN PAEDIATRIC SURGICAL PATIENTS

AIM

Local Guidelines for peri-operative pain management in children published in 2012 recommended that paracetamol dosing was calculated using ideal body weight (IBW) to prevent inadvertent overdosing in overweight and obese children.1 The purpose of this audit was to establish compliance with these guidelines. The oral paracetamol dose recommended was 20-30 mg/kg as a single dose then 15-20 mg/kg every 4-6 hrs with a maximum of 90 mg/kg/day. IV paracetamol doses were as recommended in BNF for Children (BNFC).2 BNFC states that paracetamol doses totalling 150 mg/kg may cause severe hepatocellular necrosis and renal tubular necrosis but the potential for adverse effects in some children can be seen with doses as little as 75 mg/kg in 24 hrs.

METHOD

Paediatric Surgical patients prescribed paracetamol as an inpatient or on discharge over a 10 week period were included in the audit. For this audit patients were assessed as overweight or obese using age and gender specific UK growth charts endorsed by the Department of Health.

AUDIT STANDARDS

100% compliance with the following:1. inpatient charts and discharge prescriptions document patient weight and height.2. paracetamol prescriptions based on ideal weight for height in overweight and obese paediatric patients.3. prescriptions have IV route prescribed independently to oral (PO) or rectal route.4. patients prescribed IV paracetamol reviewed after 48 hrs for an oral switch.

RESULTS

100 inpatient prescriptions (71 elective and 29 non-elective) and 35 discharge prescriptions were analysed.1. Weight was annotated for 84% of inpatient prescriptions and 94% of discharge prescriptions; height was not documented for any patient. Therefore data was analysed basing IBW on 50th centile of the UK growth charts.2. The following results are based on IBW: ▸ Six inpatients prescribed oral paracetamol were classified as overweight or obese; doses ranged from 17.4-30 mg/kg/dose. ▸ Four patients prescribed IV paracetamol were classified as overweight or obese; doses ranged from 20-23 mg/kg/dose. ▸ Four patients prescribed the combined route of PO/IV paracetamol were classified as overweight or obese; doses ranged from 18-24 mg/kg/dose. ▸ Six patients prescribed oral paracetamol on discharge were classified as overweight or obese; doses ranged from 13-33 mg/kg/dose.3. Paracetamol was prescribed as IV/PO in 32 inpatients.4. IV paracetamol was prescribed in 52 patients; 20 were not reviewed at 48 hrs for a switch to oral route. Of these, only 3 were appropriate prolonged IV prescriptions.Conclusion Audit findings showed inadequate compliance with local prescribing guidelines posing a risk of inappropriately high doses of paracetamol being prescribed to overweight and obese children. In addition, unnecessarily prolonged IV use was observed. Following feedback local guidelines were amended in 2015 to recommend that in obese children, dosing should reflect lean body mass and ideal weight for height. The maximum daily dose was also reduced to 75 mg/kg/day. Prescribers require education regarding this important issue.

THE IMPACT OF FIXED CONCENTRATIONS SEDATION INFUSIONS ON FLUID OVERLOAD IN CRITICALLY ILL CHILDREN

INTRODUCTION

Fluid overload of 10% at 48 hrs (100 ml/kg additional fluid) is strongly associated with morbidity in critically ill children.1 Contributors include fluid resuscitation, acute kidney injury, and administration of intravenous drugs. Acute Kidney Injury has been observed to be more prevalent in infants.2 Drug infusions are historically prepared according to bodyweight to run at large volumes to facilitate end-of-bed calculation and administration. We report the impact of using standardised concentrations on fluid overload in critically ill children in a tertiary general PICU.

METHODS

Administration of sedation infusions was prospectively documented using purposive sampling until a population-representative sample for age and weight was obtained. Infusion volumes were calculated in ml/kg/day for different weight groups - 0-5 kg, 5-20 kg and <20 kg - and compared with equivalent volumes for weight-based infusions.

RESULTS

33 patients received sedation infusions over a 5 week period. Overall drug volumes were reduced by 50.3%(41.3 to 58.7%) from 5.19 ml/kg to 2.65 ml/kg. Greatest reduction was seen in the smallest patients (total reduction 68% (16.72 ml/kg vs 5.36 ml/kg). Midazolam volumes in patients >20 kg was observed to increase (0.75 ml/kg vs. 0.95 ml/kg) but this did not have an impact on overall fluid burden.

CONCLUSIONS

Weight based sedation infusions may contribute to fluid overload related morbidity, especially in infants. An infant on morphine and midazolam at standard doses (20 mcg/kg/hr and 90 mcg/kg/hr respectively) will receive 16.7 ml/kg/day (33.4% of critical fluid overload at 48 hrs) when using weight-based infusions. Using standard concentrations reduces this volume to 5.36 ml/kg/day (10.7% of critical fluid overload at 48 hrs).

AN ELECTRONIC PRESCRIPTION ALERTING SYSTEM-IMPROVING THE DISCHARGE MEDICINES PROCESS

BACKGROUND

Whilst the prescribing of both in-patient and discharge medicines is electronic, there was no automatic notification to clinical pharmacists when a discharge prescription was ready to be screened. The notification required a member of medical or nursing staff to bleep their pharmacist informing them of a prescription's availability. This manual process led to a delay in pharmacist screening which impacted on discharge. Prescriptions designated for pre-packed or patient's own medicine use were not seen at all by a clinical pharmacist. The initial intention was to develop a text messaging service; however this was not possible due to significant cost implications and its inflexibility.

AIM

To decrease the time to clinical pharmacist screening for children's discharge prescriptions.

METHOD

A clinical pharmacist prescription alerting system was designed and implemented. The hospital's eDischarge Summaries are created and stored in the Trust's EPR database. A database query is executed that examines documents that have been signed by a prescriber which contain drug orders. The query runs every 15 minutes, Monday to Friday from 0800-2000. The database query exports a HTML data extract which is then packaged and sent using Exchange.Email was preferred as users access hospital WiFi, only receiving notifications on those laptops or smartphones connected to the Trust's email application. The HTML is embedded within the email body. The email is sent to named individuals within a given distribution list. The function is scalable to support all areas using Trust eDischarge Summaries.The system was introduced in April 2015. Data from before (June 2014-January 2015) and after (June 2015) implementation was compared.

RESULTS

Prior to the introduction of an electronic alerting system the average time from a prescriber signing a prescription to clinical pharmacist screening was 93 minutes. Three months after starting the new system this time has reduced to 62 minutes, a reduction of 31 minutes or 33%. During the same time period, the number of discharge prescriptions screened by pharmacists rose from 172 to 218, an increase in workload of 26%.It has been possible to intervene on prescriptions containing errors which the clinical pharmacists would not previously have screened.

CONCLUSION

The use of an electronic messaging system has met its primary aim to decrease the time delay from signing to pharmacist screening it has also increased pharmacist efficiency as evidenced by the increased workload.One limitation of this system is that it requires a regular e-mail check, for available prescriptions. The report runs every 15 minutes, an email is only sent if a prescription is found.The notification of all discharge prescriptions containing medicines has led to the identification of errors which have required intervention, in those prescriptions that a pharmacist would not have previously seen. These interventions have been for children who have received pre-packed antibiotics directly from the wards or for those where we have provided one-stop dispensing.It is hoped to role out this system across other areas of the organisation which should also enjoy this significant improvement in discharge prescription turnaround.

PROLONGED INFUSIONS OF KETAMINE AND IMPACT ON INFECTIONS AND WASTE

AIM

Ketamine is used for post-operative analgesia. There has been recent disruption in it's supply. It is usually prescribed by patient's weight (3 mg/kg in 50 ml 0.9% saline) at a rate of 1-5 ml/hr (1-5 microgram/kg/minute). To conserve ketamine supplies our policy was changed to a concentrated "standardised" concentration of ketamine (250 mg in 50 ml 0.9% sodium chloride) that could be run for a maximum of 72 hrs. There is evidence demonstrating no relationship between duration of infusion and microbiological contamination for 72 hrs.1 2 EPIC 3 guidelines recommend using infusion equipment for 72 hrs3.We carried out a service evaluation to determine if prolonged infusions were with associated infection. We also evaluated the volume of ketamine that was discarded per patient.

METHOD

125 patients received ketamine (66 patients 24 hr infusions; 59 patients prolonged infusions.) 24 patients were randomly selected (12 per group). A retrospective chart review was undertaken. Data was collected on: duration of treatment (hrs); indicators of line infection (temperature, white cells, Visual Infusion Phlebitis Score (VIP)); number of syringes administered; volume administered (in ml).

RESULTS

There were no clinical signs of infection in either cohort. No unexpected infections were reported. Concentrated ketamine ran for an average of 48 hrs per patient. 39.9% fewer syringes were used. Patients on 24 hr infusions received 55.8 ml ketamine and patients on long infusions received 51.5 ml ketamine. The amount of ketamine discarded was reduced by 65%.

CONCLUSION

Results should be interpreted with caution as patients had few co-morbidities, and received prophylactic antibiotics for surgery. These results suggest however that the risk of infusions running longer than 24 hrs is overstated. Our results raise important questions about the 24 hr expiry imposed on IV infusions. Further research on colonisation of ward-prepared infusions is needed.

CHANGING INFUSION PRACTICE GENERATES SIGNIFICANT EFFICIENCIES IN NURSING TIME AND RESOURCE USAGE IN PAEDIATRIC INTENSIVE CARE

INTRODUCTION

Infusion preparation in British PICUs uses the Rule of Six (ROS) which was developed for administration without infusion devices. This method is inaccurate.1 Regulators recommend standardised approaches to IV infusions to improve patient safety and quality of care.2 Administration set changes also have an association with resource use and central line infections.3 We report the impact of fixed concentration infusions and reduced administration set changes on nursing time and infusion equipment cost.

METHODS

Morphine and midazolam infusions were standardised in September 2014. Direct observation of infusion preparation was carried out beforeand after the introduction of fixed-concentration (FC) infusions to quantify the nursing time required to prepare infusions. Administration was prospectively documented using purposive sampling until a population-representative sample for age and weight was obtained (1 month). This data was then scaled up to predict activity over one year. Syringe use and administration set use was calculated. Reducing frequency of administration set changes to 72 hrs in accordance with infection control policy was then calculated retrospectively.

RESULTS

It takes 40 minutes (2 nurses×20 minutes) to prepare ROS syringes and 30 minutes (2 nurses×15 minutes) for FC syringes.In total ROS infusions required 2433 hrs of nursing time to prepare. FC infusions reduced this time by 25% (608 hrs) releasing 0.5 WTE nursing time back to patient care.Mean duration of IV sedation in these patients was 100 hrs. The cost associated with replacing administration sets with each syringe was £16,060. By changing every 72 hrs, this cost is reduced to £4,400 - a cost saving of £11,660.

CONCLUSIONS

FC syringes are more efficient than ROS. FC preparations have released 0.5 WTE nurses back to patient care. Changing administration sets 72 hrly realises significant cost efficiencies.

THE APPROPRIATENESS OF USING AVERAGE DISPLACEMENT VALUES FOR PAEDIATRIC INTRAVENOUS DRUG ADMINISTRATIONS

AIM

To determine the impact of displacement values on doses in paediatric patients when using parenteral. To assess the option of using average displacement values (DV) in the preparation of parenteral medicines.

METHOD

Over 500 Medusa1 monographs were analysed and 42 medicines were identified with a displacement value not indicated as negligible. The following were calculated: the percentage difference in dose if the DV was not taken into account for each drug and brand, the range of percent differences where there was more than one brand for each strength and the percentage difference in dose incurred if an average DV was used.

RESULTS

The 42 drugs were separated into 3 groups. The first group of 27 drugs had DVs causing less than 5% dose variation for all brands. The second group of 7 drugs had DVs resulting in more than 5% dose variation. The third group of 8 drugs had wider variations i.e. including drugs where the different brands had DVs both below and above 5% (2 to 27.9%) in dose variations for varying brands of a drug and strength.A total of 64 preparations had less than 5% dose variation. For these the DVs could potentially be disregarded as it is unlikely to have a significant clinical effect. However there are other sources of errors when administering parenteral medications (e.g. dose rounding on prescribing, inaccuracy when preparing and drawing up the dose) and this may further contribute to cumulative dosing inaccuracies. An alternative option would be to provide an average DV for each drug and vial strength. Due to the use of an average DV under or over dosing can occur depending on the preparation. However if this method was used the dose difference is only 0.31% on average (0.47-0.98%), significantly less if the DV was ignored.For the second group of preparations with dose differences greater than 5% (5-18%), the DV should not be ignored as it can be clinically significant. However where there is more than one manufacturer available for a particular strength of drug the range in difference of the dose variation was small (0.7-4.1%). When an average displacement value was attributed this resulted in a maximum dose difference of 2.5% (0-2.5%). For the third group there are varying differences in the range of dose variation. Where the range is small and an average was assigned the average range in dose variation was 0.30% (0-4.6%). However there are preparations that the range was too wide for an average to be safely used (2.8-9.5%).

CONCLUSION

For the majority of drugs an average DV can be used safely. Using average DVs would simplify the preparation process for nurses and reduce the risk of them inadvertently using the wrong displacement value.

CHILDREN WITH CYSTIC FIBROSIS: UNDERSTANDING ISSUES RELATED TO ORAL ADMINISTRATION OF LIQUID FLUCLOXACILLIN

AIM

Palatability of flucloxacillin is poor, yet is used long-term in the management of children with cystic fibrosis (CF). Strategies to aid administration of unpalatable medicines have been reported, however there has never been a systematic approach to gathering views of many parents/carers all administering the same medication to the same population of children. This study aimed to quantify the extent of flucloxacillin palatability issues for parents/cares of children with CF and identify parent/carer and healthcare professional (HCP) reported age-specific strategies to aid administration of flucloxacillin to children with CF.

METHOD

Passive analysis reviews of public online forums were conducted using search terms including, 'flucloxacillin' and 'taste' or 'palatability' or 'child' to identify evidence of tactics used by parents to aid administration of flucloxacillin to children, not only those with CF (strategies were only included if the age of the child was disclosed). A bespoke online questionnaire was developed and partially validated for parents/carers of children with CF to identify age-specific strategies to aid administration of flucloxacillin. Healthcare professionals (HCPs) were purposively selected for semi-structured interviews to further explore age-specific strategies to aid administration of flucloxacillin.

RESULTS

18 individual strategies were identified on 10 different public online forums to aid the administration of flucloxacillin to children. These included mixing with food/drink: milk was commonly used for children aged 6-20 months; honey, Nutella, jam, ice cream and squash for those aged 21-36 months. The use of an oral syringe to direct the medicine slowly into the back/side of the mouth, and pinching a child's nose was reported.253 parents/carers of children with CF completed the online survey and 11 HCPs were involved in the semi-structured interviews. 50.2% of parents/carers reported that administration of flucloxacillin was problematic, yet 89.3% reported that they administered 'most' or 'all doses' of flucloxacillin. 90.5% of parents/carers found administration of flucloxacillin more problematic than other medicines in pre-weaned babies. 162 of 253 parents/carers chose to comment on ways that administration of flucloxacillin could be improved/eased, with 38.3% of these respondents suggesting improved palatability was necessary. Mixing with food/drink was rarely reported by parents/carers of children with CF (15.9%) or HCPs (27.3%), contrary to data identified within online forums. This difference highlights that parents of children with CF are less likely to use food to aid administration compared to those using flucloxacillin for acute infections. A multi-methods approach to obtain information on manipulation of medicines by parents/carers would provide greater insights into explaining this finding.

CONCLUSION

The results from this study showed that flucloxacillin is unpalatable and that parents/carers use a range of strategies to improve acceptability of this product. Although food is an obvious strategy for making flucloxacillin more palatable when treating an acute infection; it may be that this doesn't work in longer term therapy (eg CF) and the wider population can learn from parents/carers with more experience with this medicine. Parents of children with CF and HCPs have provided useful age-specific strategies to ease administration of the known poorly tolerated medicine, liquid flucloxacillin.

RATES AND TYPES OF PRESCRIBING ERRORS AND RELATED INTERVENTIONS IN PAEDIATRIC ONCOLOGY

AIM

The aim of the pharmacy intervention audit was to prospectively record the number and type of interventions made to paediatric oncology chemotherapy prescriptions. This baseline data will be used in the future to assess the impact of electronic prescribing (EP) on prescribing error or intervention rates.Independently from the EP project research, I interrogated the data to establish if there was a correlation between prescribing workload and rate of errors or interventions. I predicted that an 'overworked' prescriber would make more mistakes due to the volume of the workload and a less frequent prescriber would make more mistakes due to scarce use of these skills.Intervention rates have been found to be as high as 66% for chemotherapy prescriptions, including interventions for missed information, wrong doses and protocol breach1. This intervention rate demonstrates the importance of pharmacy verification. Another source demonstrated that 80% of errors were due to poor prescription writing.2 METHOD: An audit tool was created to collect the data, included fields for date, prescriber type, number of drugs prescribed, number of interventions made and intervention type. Data was collected from 5 Jan 2015 to 12 Jun 15.

RESULTS

The most common interventions required were addition of diluent volume, addition of start date and dose amendments to ensure doses could be accurately measured.The staff grade doctor prescribed on average 75% of the prescriptions each week, with an intervention rate of 19%. The registrar was responsible for 23% each week and had an error rate pf 24%. Consultants were responsible for only 2% of the weekly prescription workload and had the lowest rate of interventions at 7%. There was no clear correlation between percentage of chemotherapy prescribed per week and rate of errors.

CONCLUSION

The most common types of errors expected from the background reading are demonstrated by this audit, as the three common interventions are related to poor prescribing. EP should eliminate all three of these interventions as all these are either mandatory fields for a prescription to be ordered or measurable dose rounding will be in inbuilt into each drug field, and therefore calculated automatically by our prescribing system.There was no clear correlation between error rate and proportion of prescribing. Errors are therefore independent of prescribing workload. Alternative reasons for errors could include external factors such as environment or bad habits of the prescriber. I believe the low rate of errors from the consultants is due to the types of prescriptions they often prescribe. Which were more frequently for single agents such as intrathecals. This suggests further data interrogation could identify whether there is a relationship between prescription complexity (or length) and error rate.

AN AUDIT TO ASSESS THE TIMINGS OF TTAS AND INPATIENT ORDERS IN PAEDIATRICS; FROM WRITING, TO SCREENING, TO DISPENSING, AND TO LEAVING DISPENSARY

AIM

To assess the time it takes for paediatric TTA and inpatient orders to be dispensed and sent to ward. This is to establish if the Trust is meeting an operational Key Performance Indicator (KPI).

STANDARDS KPIS

▸ 85% of urgent items (TTAs) dispensed within 1 hour.▸ 85% of non-urgent items (most inpatient orders) dispensed within 3 hrs.

METHOD

To audit the time it takes for TTAs and inpatient orders to be screened, sent to dispensary, labelled, dispensed, checked, and leave dispensary. Data collection took place over 5 days and focused on TTAs and inpatient orders coming from high turnover paediatric wards.Data was collected on: time to verify, time logged into dispensary, time for labelling, time for checking, and time to leave dispensary.

EXCLUSION CRITERIA

TTAs/ inpatient orders that contain controlled drugs, requires a dosette box, or is ordered out of hours.

RESULTS

TTA results:The time from writing to screening of TTAs averages 1 hour 34 minutes. However, this may be inaccurate as it requires the doctor to select 'sign and send to pharmacy'. If not selected, the clock has started, but the TTA is not visible to pharmacy.It took on average 2 hrs for all items from being logged in to being checked (n=12). The standard is 1 hour. The rate limiting steps were time to screen and time to label (each of which took approx. 1 hour 30 mins).The majority of the dispensing time is spent labelling, with an average time from logging in to labelling being 1 hour 25 minutes. The dispensing and checking was quick with an average of 36 minutes.

INPATIENT RESULTS

Inpatient orders took on average 5 hrs 51 minutes for the items to leave dispensary after they had been logged in (n=22). The standard for non-urgent work is 3 hrs.Time to screen was not recorded as the doctors do not record the time of prescribing on the inpatient drug chart. There is only a 6 minute delay between faxing orders and it being logged in, therefore no problem identified at that stage.The majority of time was spent labelling, with an average time from logging in to labelling being 1 hour 56 minutes.

CONCLUSION

Standards are not being met. The rate limiting steps appears to be labelling in dispensary.

PROPOSALS

▸ Additional staff labelling at peak times▸ Slow dispensing system, liaise with IT to see if improvements can be made▸ Unable to have more labelling terminals as the robot only has three shoots▸ Induction teaching to include importance of sending TTAs to pharmacy after writing▸ Re-audit in 3 months

LIMITATIONS

Lack of dataThe screening time for TTAs is misleading as it captures the time from writing (rather than time of sending to pharmacy), until the time screened.No data on time taken for items to arrive back onto the ward, or if medicines collected or delivered by porter.