Abstracts of the RCPCH Conference

The proceedings contain 839 papers. The topics discussed include: parental attitudes regarding safe handling of hand sanitizers and management of children with sanitizer poisoning amongst a cohort of children admitted to a tertiary care center in Sri Lanka;pediatric major incident triage and the use of machine learning techniques to develop an alternative triage tool with improved performance characteristics;unfair and unequal: comparing the experiences and outcomes of children with acute mental health and acute physical health presentations to the pediatric emergency department;tackling child inequality in a UK emergency department: a pilot early intervention service on the shop floor;introducing a new pediatric clerking proforma in a tertiary pediatric emergency department - a quality improvement project;changing patterns of bronchiolitis attendances to the emergency department in the COVID-19 pandemic;investigating prescribing errors in salbutamol nebulizers for acute asthma patients aged 5 and above in a district general hospital;assessment for testicular torsion in a DGH hospital- a service review;and changing spectrum of children presenting with asthma and viral induced wheeze in the COVID -19 pandemic.

CLINICAL INTERVENTIONS IN THE AREA OF INPATIENT PRESCRIPTIONS PERFORMED BY A HOSPITAL PHARMACY RESIDENT

Background and importance Pharmaceutical validation of inpatient treatments is a fundamental activity in the clinical practice of the hospital pharmacist. Thanks to this, many prescription errors are detected, promoting patient safety. Aim and objectives To describe the interventions performed by a hospital pharmacy resident in the area of pharmaceutical validation, supervised by consultant pharmacists, and to evaluate their degree of acceptance. Material and methods Prospective interventional study conducted during September 2021. Adult inpatients, whose hospital treatment was reviewed, were included. Demographic (sex and age), clinical (clinical judgement (CJ) and inpatient clinical service) and pharmacotherapeutic (number of chronic medicines and polymedication (≥6 drugs)) variables were collected. Interventions were reported to the clinician via electronic prescribing software. They were classified as: Activity (reconciliation on admission/information to the clinician), Adequacy (detection of prescribing error/therapy reconciliation error), Change (therapeutic exchange), Initiation (usual treatment not prescribed/need for additional treatment), Modification Dosage Form (DF) or Posology, Suspension (duplicity/unnecessary medication/allergy). Patient lists and data were collected through medical records and electronic prescribing software, and processed using Excel 2020. Results Interventions were performed in 56 patients. 63.2% male;median age 73 years (IQR 61-80). The most frequent CJ were: heart failure (10.7%), COVID-19 (7.1%), liver dysfunction (7.1%). Services with most interventions: Internal Medicine (25.8%), General/Vascular Surgery (19.4%), Digestive (11.3%). Median number of chronic medicines: 8 (IQR 5-12). Polymedication in 71.4%. 62 interventions were performed (12.9% were 'not evaluable', reasons: discharge/death). Of the evaluable interventions, 77.8% were accepted. The percentages were: duplicity (30.9%), modification DF/posology (23.8%), usual treatment not prescribed (7.1%), therapeutic exchange (7.1%), discontinue medication due to allergy (7.1%), therapy reconciliation error (4.8%), reconciliation on admission (4.8%), information (4.8%), additional treatment (4.8%), prescribing error (2.4%), unnecessary medication (2.4%). Of the accepted interventions, 11.9% were related to high-risk medicines according to the Institute for the Safe Use of Medicines1- 2 (nonsteroidal anti-inflammatory drugs (NSAIDs), betablockers, heparin, immunosuppressants). Of the not-accepted interventions, 50.0% corresponded to errors in home treatment reconciliation. Conclusion and relevance The data obtained demonstrate that clinical interventions performed by the hospital pharmacy resident have a high degree of acceptance, increasing the quality and safety of healthcare and avoiding medication errors.

VOLUNTARY ELECTRONIC REPORTING OF MEDICATION ERRORS AND ADVERSE DRUGS EVENTS DURING THE FIRST YEAR OF THE COVID-19 PANDEMIC

Background and importance Evidence regarding the rate of medication errors (ME) and adverse drugs events (ADE) during the COVID-19 pandemic is limited. In that period the risk of ME and unsafe medication practices was potentially higher than average. Thus, voluntary hospital reporting systems are valuable sources of information on ME and ADE. Aim and objectives To describe the ME and ADE registered in the voluntary electronic notification system of our centre (TPSC Cloud) during the first year of the COVID-19 pandemic and compare them with the same period in the previous year. Material and methods A retrospective observational study of ME and AE notifications in the TPSC Cloud from March 2020 to February 2021 compared to notifications recorded from March 2019 to February 2020. Five types of incidents were differentiated: situations with the capacity to cause ME, ME that do not reach the patient, ME that reach the patient without ADE, ME with ADE, and ADE without ME. The drugs involved in those incidents and the professional notifier also were identified. Results 249 incidents were reported from March 2020 to February 2021, which was 31.02% less than in the previous period (n=361) from March 2019 to February 2020. The most common ME was prescription error in both periods (70.4% vs 67.3%). The incident profile by typology was similar in both periods. The most frequent was ME that did not reach the patient (40.24% vs 43.47%), followed by ME that reached the patient without ADE (23.42% vs 28.53%). Systemic anti-infectives drugs were the most involved in both periods (n=57;22.89% vs n=73;20.22%). 84 ADE without ME were reported from March 2020 to February 2021, representing an increase of 500% compared with March 2019 to February 2020 (n=14). Emphasising the notification of 35 ADE of lopinavir/ritonavir and 4 of hydroxychloroquine used in the initial treatment of COVID-19. The main notifier in both periods was the pharmacist (80.48% vs 65.60%). Conclusion and relevance During the first COVID-19 pandemic year, notifications of ME decreased, due to care load pressure, but incident profile was similar. Otherwise, ADE notifications increased notably, due to active pharmacovigilance carried out by pharmacists on off-label drugs used to treat COVID-19.

The impact of clinical pharmacist implemented education on the incidence of prescribing errors in COVID-19 patients.

Background: Clinical pharmacists have a vital role during COVID-19 pandemic in mitigating medication errors, particularly prescribing errors in hospitals. That is owing to the fact that prescribing errors during the COVID-19 pandemic has increased. Aim: This study aimed to evaluate the impact of the clinical pharmacist on the rate of prescribing errors on COVID-19 patients in a governmental hospital. Methods: The study was a pre-post study conducted from March 2020 till September 2020. It included the pre-education phase P0; a retrospective phase where all the prescriptions for COVID-19 patients were revised by the clinical pharmacy team and prescription errors were extracted. Followed by a one-month period; the clinical pharmacy team prepared educational materials in the form of posters and flyers covering all prescribing errors detected to be delivered to physicians. Then, the post-education phase P1; all prescriptions were monitored by the clinical pharmacy team to assess the rate and types of prescribing errors and the data extracted was compared to that from pre-education phase. Results: The number of prescribing errors in P0 phase was 1054 while it was only 148 in P1 Phase. The clinical pharmacy team implemented education phase helped to significantly reduce the prescribing errors from 14.7/1000 patient-days in the P0 phase to 2.56/1000 patient-days in the P1 phase (p-value <0.001). Conclusion: The clinical pharmacist significantly reduced the rate of prescribing errors in patients with COVID-19 which emphasizes the great role of clinical pharmacists' interventions in the optimization of prescribing in these stressful conditions.

WHAT SHOULD YOU ANTICIPATE AND PREPARE FOR DURING A PANDEMIC - CONVERSION OF A PAEDIATRIC INTENSIVE CARE UNIT TO AN ADULT INTENSIVE CARE UNIT - A PHARMACY PERSPECTIVE

Aim On 12 March 2020, the COVID-19 outbreak was declared as a pandemic by the World Health Organisation.1 During this time, paediatric services saw dramatic reductions in children accessing emergency care and routine operations were cancelled, which enabled the paediatric intensive care unit (PICU) team to support the adult critical care expansion by repurposing paediatric beds to open an adult intensive care unit (AICU). Here we describe the pharmacy experience, challenges and learning outcomes faced in converting a PICU to an AICU. Method A trust-wide multidisciplinary critical care tactical group including pharmacy representation was established to coordinate strategy planning, troubleshoot operational and clinical difficulties, and manage communications on a wider scale. Within pharmacy, clinical and operational lead pharmacists led the pharmacy response and supported the front-line pharmacy teams to coordinate and make quick informed decisions to daily challenges. The challenges were made even greater by the need to co-deliver a mixed paediatric/adult unit meaning we had to ensure the safety of both the adults and children receiving medicines. Results Paediatric pharmacy staff were upskilled by the adult critical care pharmacy team, extrapolating existing PICU knowledge and experience and expanding on key differences, as well as offering weekly shadowing opportunities. The use of a mnemonic pharmaceutical tool to review patients enabled paediatric pharmacists to ask the right questions and ensure medicines were managed appropriately. In addition, a quick reference guide to common adult drug doses, bite size educational sessions and use of an app called Clinibee® were developed to disseminate important adult learning points and new guidance. The PICU electronic prescribing system Metavision® was adapted and configured for adult dosing and administration. To reduce prescribing errors and improve safety, doctors on the unit were assigned to either managing adults or paediatric patients. Further informatic changes were required in real time in response to drug supply chain and equipment shortages and changes in clinical policies. A risk assessment of adult medicine stock holding, including high-risk medicines and location of them on the unit helped reduce the risk of mis-selection. Extra nursing support was provided by pharmacy by manufacturing ready to administer injectables and existing medicines management policies adapted. Regular check-ins and staff huddles kept staff updated and provided support where needed. Conclusion Providing an AICU on PICU was one of the biggest challenges ever faced but provided excellent cooperation and collaboration between pharmacy teams. PICU pharmacists have a strong foundation of ICU knowledge to enable them to be redeployed to AICU. Strong clinical and operational leadership is required to navigate uncertain times when staff are working outside their normal practice. Good communication is vital, both upwards, downwards and to the front line to ensure safe ways of working. Resilience planning including staffing, drug and equipment shortages ensured that resources were prioritised. Teamwork with a dedicated focus on wellbeing enabled staff to be supported where needed and ensured our patients received the most clinically effective care.

An assessment of the quality of care and outcomes of inpatients with covid-19 and diabetes

Aim: It is now known that patients with diabetes, who are admitted with covid-19 infection (PWCD), generally have worse outcomes compared to those without diabetes. This study aims to assess the quality of diabetes care provided, and outcomes in such patients. Method: We compared outcomes of the PWCD group with the patients with covid-19 (PWC) group, without diabetes. We also compared the quality of care of a subset of PWCD with a matched group of people with diabetes but no covid-19 infection (PWD). Results: 74 of 411 people with covid-19 admitted, had diabetes (PWCD). Mean length of stay was slightly longer for the PWCD group. The diabetes group were significantly older, and had a significantly higher BMI. Prescription errors were significantly higher in the PWCD group compared to PWD (29 vs 14). Diabetes medication administration errors were also found to be higher in the PWCD group compared to PWD (84 vs 20). Interestingly, number of good glucose days (4 to 12mmol/L) was marginally better in the PWCD group (15) compared to PWD (13). Conclusion: As previously described, the PWCD cohort has more risk factors and mortality as inpatients. Our novel finding is that the quality of diabetes care was worse for the covid-19 and diabetes cohort. Inpatient diabetes teams need to specifically focus on the quality of diabetes care for this group to hopefully help improve outcomes.

Outpatient Antimicrobial Stewardship Utilizing a Decentralized Model

Background. The majority of human antimicrobial utilization occurs in the outpatient setting. Despite being mainly viral in etiology, upper respiratory tract infections (URIs) were the most common indication for outpatient antimicrobial prescriptions at our institution. Methods. Through our electronic health record (EHR), we were able to determine our rate of antibiotic prescriptions for inappropriate URI diagnosis at our primary care practice sites. We selected staff volunteers from each our primary care practice sites to serve as stewardship champions. They were given training in stewardship best practices, and an URI stewardship toolkit which included viral URI prescription pad, EHR order panel, and patient education signage. They were tasked with providing education and feedback to their practice sites. We meet with them on a monthly basis to disseminate prescribing data and education. They also provided feedback from practice sites to the stewardship committee. Results. Our decentralized model was put in place in November 2020. In the 6 months prior to the intervention, the average prescribing rate was 29.1%. In the 6 months after the intervention, the average prescribing rate decreased by 15% to 24.8%. During the intervention phase, there was an increase in number of non-COVID URIs diagnosed at our primary care sites. Temporal Trend in Inappropriate Antibiotics Prescribing Rates for Viral URIs Preand Post- Intervention Inappropriate antibiotic prescribing rate for viral upper respiratory tract infections from May 2020 until May 2021. Intervention started in December 2021 (arrow). Preintervention average was 29.1%. Post-intervention age was 24.8% which is a 15% decline in prescribing rate. Viral Upper Respiratory Infections Visits The total number of visits for presumed viral upper respiratory infections to primary care sites from May 2020 until May 2021. The majority of COVID-19 precautions in the area expired at the end of March 2021. Conclusion. We have been able to lower our inappropriate prescriptions for URIs utilizing a decentralized model of stewardship champions. This result was especially notable as the intervention phase corresponded with the end of COVID-19 precautions and an increase in non-COVID URIs diagnosed. The advantage of this approach includes an advocate embedded at each practice site who is familiar with the opportunities and challenges of the site, and a two-way flow of information from practice sites to the stewardship committee. This model provided additional benefit during the COVID-19 pandemic as the ability of centralized staff to travel to off campus clinic sites was curtailed.

Appropriateness of Antibiotic Prescribing Through the COVID-19 Pandemic and Associated Telehealth Visits

Background. The COVID-19 pandemic and resulting mitigation strategies have impacted rates of outpatient infections and delivery of care to pediatric patients. Virtual healthcare was rapidly implemented but much is unknown about the quality of care provided in telehealth visits. We sought to describe changes in visits throughout the pandemic and evaluate the appropriateness of antibiotic prescribing. Methods. We utilized EHR data from a large health care system that provides primary care via pediatric, family medicine, and urgent care clinics. We included outpatient visits from 1/1/19 - 4/30/21 for children < 20 years. The COVID-19 era was defined as after March 2020. Visits were labeled as virtual according to coded encounter or visit type variables. The appropriateness of antibiotic prescriptions was assigned using a previously published ICD-10 classification scheme that defines each prescription as appropriate, potentially appropriate, or inappropriate (Chua, et al. BMJ, 2019). Results. There were 805,130 outpatient visits during the study period. The mean rate of antibiotic prescriptions in the pre-pandemic period was 23% (range 17-26% per month) and 11% (range 9-15%) in the COVID-19 era. Mean rates of inappropriate prescribing were 17% (range 14-20% per month) and 20% (range 19-22%), respectively (Figure 1). Coded virtual visits during the COVID-19 era were uncommon (1-2%) with the exception of April and May 2020 (11% and 5%, respectively). During the COVID-19 era, approximately 9% of telehealth visits resulted in antibiotics, compared to 11% of in-person visits (Table 1). Virtual visits had lower rates of inappropriate and appropriate prescribing, but higher rates of potentially appropriate prescribing (Table 1). Visits and associated antibiotic prescribing in the pre-pandemic and COVID-19 era Appropriateness of antibiotic prescribing in the COVID-19 era, by visit type Conclusion. Rates and volume of antibiotic prescribing in outpatient pediatric visits have declined in the COVID-19 era, while rates of inappropriate prescribing have increased slightly. Our study suggests use of telehealth for pediatric visits was minimal and led to higher prescribing rates for "potentially appropriate" indications. This could be explained by a lack of clinical certainty in conditions such as otitis media and pharyngitis in virtual visits.