Standardising care-northern ireland regional paediatric gentamicin chart

ABSTRACT

Background Gentamicin is one of the most commonly reported medications associated with drug errors amongst paediatric inpatients.1 Such errors include inappropriate dosing, insufficient monitoring and lack of awareness of its role in acute kidney injury (AKI). As with other aminoglycosides, gentamicin side-effects are dose-related, highlighting the significance of dose calculation and therapeutic monitoring. Collaborative services is one of the key recommendations from the RCPCH standards for paediatric care.2 Within Northern Ireland there is a well-established regional neonatal gentamicin prescription chart, however, it has previously lacked a paediatric equivalent. Lack of standardisation of practice across units is a common source of frustration for paediatric trainees and trainers. It also contributes to variations in care across Northern Ireland. Objectives To improve gentamicin prescription, drug monitoring and avoidance of nephrotoxicity, through the design, implementation and evaluation of a standardised gentamicin prescription chart for children (one month to sixteen years old). Particular emphasis was placed on dose adjustment and close monitoring in renal impairment, and ideal-body-weight (IBW) for height prescribing in grossly oedematous or overweight children. Additionally, a stronger focus was placed on antibiotic stewardship. For instance, following two gentamicin doses the prescriber is prompted to review diagnosis, culture results and on-going antimicrobial indication. A further prompt for Paediatric Infectious Diseases discussion is highlighted in treatment courses exceeding five doses. Methods A rapid-fire PDSA QI approach was employed, with contribution from Paediatric Infectious Diseases, Paediatric Nephrology and Pharmacy departments. The team pursued this project during the COVID-19 pandemic, despite some initial colleague hesitancies. Throughout implementation, the chart design, content and accessibility were regularly scrutinised. An initial three month pilot was conducted in RBHSC PICU & surgical ward (August- November 2020), prior to hospital-wide adoption. Pre- and post- implementation multidisciplinary education sessions helped to embed its clinical use and facilitate user feedback. Following pilot, the chart was amended to include specific instructions to review both anaesthetic and emergency department records, to ensure gentamicin doses weren't missed. An audit of toxic gentamicin levels (≥1), renal function monitoring and associated AKI was conducted, comparing serum gentamicin levels sent in the 6 months prior to and following chart introduction. Quantitative and qualitative staff feedback was also obtained. Results Audit data showed improvement in renal function monitoring (84.6% to 100%) and associated reduction in AKI (33.4% to 22.2%), following chart introduction. However, similar levels of gentamicin toxicity were encountered before and after chart implementation (9.8% and 10.7% of all gentamicin results respectively). Staff feedback was overwhelmingly positive, with 100% of prescribers agreeing the chart enhanced their knowledge of therapeutic drug monitoring, and prescription and monitoring in renal impairment. Furthermore, regional implementation was supported by all survey respondents. New relationships with laboratory colleagues has facilitated the development of an auto-analysis function to process creatinine results when serum gentamicin levels are requested;this will help to limit clinician variability and may prompt enhanced AKI recognition. Conclusions A collaborative, multi-professional approach to a standardised gentamicin prescription chart will help to harmonise paediatric clinical care throughout Northern Ireland and may contribute to improved antimicrobial prescribing, monitoring and stewardship.