Outcomes of a Vial-Sparing Antithrombin III Protocol in Pediatric Extracorporeal Membrane Oxygenation.

Exogenous antithrombin III (AT3) may be administered to pediatric patients supported by extracorporeal membrane oxygenation (ECMO) to achieve a greater systemic response to heparin. Antithrombin III administration and dosing practices vary between ECMO centers. This study compared the outcomes of two different AT3 replacement protocols used by a single pediatric ECMO center for 47 patients between December 2013 and August 2021. In May 2016, a weight-based continuous infusion protocol (WBP) was transitioned to a vial-sparing protocol (VSP) as a cost-saving measure. No difference was observed in the percentage of heparin monitoring levels within goal range, with a median of 56.5% therapeutic levels on the WBP compared with a median of 60.7% on the VSP ( p = 0.170). No significant differences were observed in amount of exogenous blood products administered, number of hemorrhagic or thrombotic events, number of mechanical failures, or number of circuit changes required. The VSP resulted in fewer AT3 dispenses ( p < 0.001) and units dispensed ( p = 0.005), resulting in a significant median cost reduction from $15,610.62 on the WBP to $7,765.56 on the VSP ( p = 0.005). A vial-sparing AT3 replacement protocol resulted in significant cost savings with similar efficacy and safety outcomes.

Pharmacist-Led Discharge Transitions of Care Interventions for Pediatric Patients: A Narrative Review.

Transitions of care (TOC) before, during, and after hospital discharge are an opportune setting to optimize medication management. The quality standards for pediatric care transitions, however, are lacking, leading to reduced health outcomes in children. This narrative review characterizes the pediatric populations that would benefit from focused, TOC interventions. Different types of medication-focused TOC interventions during hospital discharge are described, including medication reconciliation, education, access, and adherence tools. Various TOC intervention delivery models following hospital discharge are also reviewed. The goal of this narrative review is to help pediatric pharmacists and pharmacy leaders better understand TOC interventions and integrate them into the hospital discharge process for children and their caregivers.

Effect of a Pharmacist-Led Discharge Counseling Service at a Children's Hospital.

OBJECTIVE: To evaluate the effect of a pharmacist-led discharge counseling service at a pediatric hospital. METHODS: This was a prospective observational cohort study. Patients in the pre-implementation phase were identified by the pharmacist at the time of admission medication reconciliation, whereas patients in the pos-timplementation phase were identified at the time of pharmacist discharge medication counselling. Caregivers were contacted within 2 weeks of the patients' discharge date to complete a 7-question telephone survey. The primary objective was to measure the effect of the pharmacist-led service on caregiver satisfaction, using a pre- and post- implementation telephone survey. The secondary objectives were to evaluate the effect of the service on 90-day medication-related readmissions and determine the change in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey response (Question 25) regarding discharge medications following implementation of the new service. RESULTS: A total of 32 caregivers were included in both the pre- and post-implementation groups. The most common reason for inclusion was high-risk medications (84%) in the pre-implementation group and device teaching (62.5%) in the post-implementation group. The primary outcome, the average composite score on the telephone survey, was 30.94 ± 3.50 (average ± SD) in the pre-implementation group and 32.5 ± 2.26 in the post-implementation group (p = 0.038). There were no medication-related readmissions within 90 days in either group. The score on HCAHPS Question 25 was not different between groups (p = 0.761). CONCLUSIONS: Implementation of a pharmacist-led discharge counseling service in pediatric patients improved caregiver satisfaction and understanding as shown by a postdischarge telephone survey.

Incidence of Medication-Related Problems Following Pediatric Epilepsy Admissions.

BACKGROUND: An estimated 26% to 33% of pediatric patients have at least one medication error at hospital discharge. Pediatric patients with epilepsy may be at greater risk due to complex medication regimens and frequent hospitalizations. This study aims to quantify the proportion of pediatric patients with epilepsy experiencing medication problems after discharge and determine if medication education decreases these problems. METHODS: This was a retrospective cohort study including pediatric patients with epilepsy-related hospital admissions. Cohort 1 consisted of a control group, and cohort 2 consisted of patients who received discharge medication education, enrolled in a 2:1 ratio. The medical record was reviewed from hospital discharge to outpatient neurology follow-up to identify medication problems that occurred. The primary outcome was the difference in proportion of medication problems between the cohorts. Secondary outcomes were incidence of medication problems with harm potential, overall incidence of medication problems, and 30-day epilepsy-related readmissions. RESULTS: A total of 221 patients were included (163 in the control cohort and 58 in the discharge education cohort) with balanced demographics. The incidence of medication problems was 29.4% in the control cohort and 24.1% in the discharge education cohort (P = 0.44). The most common problems were mismatched dose or direction. Medication problems with harm potential were 54.2% in the control group and 28.6% in the discharge education cohort (P = 0.131). CONCLUSION: Medication problems and their harm potential were lower in the discharge education cohort, but the difference was not significant. This demonstrates education alone may not be enough to impact medication error rates.

Effect of a Pharmacist Admission Medication Reconciliation Service at a Children's Hospital.

OBJECTIVE: To evaluate the clinical effect and estimate cost avoidance attributed to a pharmacist-led admission medication reconciliation service at a children's hospital. METHODS: This was a prospective observational cohort study that measured pharmacist interventions for pediatric patients over a 90-day period. Pharmacists logged all interventions identified during medication reconciliation in real time. Patient demographic data were collected retrospectively. Cost avoidance from prevented adverse drug events (ADEs) was estimated based on previously published literature. RESULTS: Pharmacists completed 283 admission medication reconciliations during the study period. Of those, 69% of medication reconciliations required intervention. Interventions affected care during the hospital admission in 21.9% of patients and 8 medication reconciliations resulted in prevention of a major ADE. This pharmacist-led service resulted in an estimated cost avoidance of $46,746.65 in the 3-month period. CONCLUSIONS: Implementation of a pharmacist-led admission medication reconciliation service for pediatric patients improved medication safety and resulted in significant cost avoidance, which justifies investment in these pharmacist resources.

Implementation of a Pharmacist-Driven Vancomycin and Aminoglycoside Dosing Service in a Pediatric Hospital.

OBJECTIVE: Pharmacy-driven antibiotic dosing services have been shown to improve clinical outcomes in adult patients. This study evaluated the effect of a pharmacist-driven antimicrobial dosing service on the percentage of therapeutic serum concentrations achieved following initial vancomycin or aminoglycoside dosing regimens. A secondary objective was to determine the effect of the dosing service on nephrotoxicity in pediatric patients. METHODS: This single-center, retrospective study used data obtained from an electronic medical record to evaluate the utility of a pharmacist-driven vancomycin or aminoglycoside dosing protocol. Assessments of target, subtherapeutic, and supratherapeutic serum concentrations were evaluated. The occurrence of changes in serum creatinine and presentation of acute kidney injury (AKI) were also determined. RESULTS: The incidence (n [%]) of a therapeutic initial serum concentration was not statistically significant between pre-protocol and post-protocol groups (21 [46.7%] vs 22 [48.9%], respectively; p = 0.834). The incidence of initial supratherapeutic concentrations (19 [42.2%] vs 7 [15.6%]; p = 0.005) and the average number of supratherapeutic concentrations per antibiotic course (0.76 vs 0.26; p = 0.01) were higher in the pre-protocol group compared with the post-protocol group. The incidence of AKI was significantly lower in the post-protocol group (2.2% vs 13.3%; p = 0.049). CONCLUSIONS: Implementation of a pharmacist-driven dosing service did not affect the likelihood of achieving an initial therapeutic concentration. However, it did reduce the likelihood of both supratherapeutic concentrations and AKI. Additional studies in pediatric patients are needed to affirm the use of pharmacist dosing services.

Valproic Acid Serum Concentration and Incidence of Toxicity in Pediatric Patients.

In certain pediatric patients on valproic acid, therapeutic range (50-100 µg/mL) is maximized or exceeded to achieve better seizure control. This study compared incidence of common valproic acid adverse effects (thrombocytopenia, hepatotoxicity, and hyperammonemia) across maintenance concentration and age group. One hundred twenty-four children on maintenance valproic acid between January 2013 and January 2021 were eligible for inclusion. Fifty-six patients were maintained in concentration range 50 to 80 µg/mL, an additional 44 between 80 and 100 µg/mL and 24 between 100 and 120 µg/mL. Forty-one patients were prepubescent, 57 pubescent, and 26 postpubescent. There were no statistically significant differences observed in the primary endpoint of thrombocytopenia across serum concentration range (P = .093) or age group (P = .628). No significant differences in hepatic dysfunction (P = .099) or hyperammonemia (P = .548) were observed in serum concentration groups. Similarly, age group analysis observed no difference in hepatic dysfunction (P = .615) or hyperammonemia (P = .369). Serum valproic acid levels >100 µg/mL can be considered in select pediatric patients based on this study.

Improving Timeliness of Insulin Administration by Using an Insulin Dose Calculator.

OBJECTIVES: Insulin is a high-risk medication, and its dosing depends on the individualized clinical and nutritional needs of each patient. Our hospital implemented an insulin dose calculator (IDC) imbedded in the electronic medical record with the goal of decreasing average wait times in inpatient insulin ordering and administration. In this study, we evaluated whether implementation of an IDC decreased the average wait time for insulin administration for hospitalized pediatric patients. METHODS: This pre- and postintervention cohort study measured wait times between point-of-care glucose testing and insulin administration. Patients admitted to the inpatient pediatric services who were treated with subcutaneous insulin during the study period were included. Additionally, nurses completed satisfaction surveys on the insulin administration process at our hospital pre- and post-IDC implementation. Descriptive statistics, χ2, Fisher's exact test, and Student t tests were used to compare groups. Statistical process control charts were used to analyze data trends. RESULTS: The preintervention cohort included 79 insulin doses for admitted pediatric patients. The postimplementation cohort included 128 insulin doses ordered via the IDC. Post-IDC implementation, the average wait time between point-of-care glucose testing and insulin administration decreased from 37 to 25 minutes (P < .05). The statistical process control chart revealed a 5-month run below the established mean after implementation of the IDC. Before IDC implementation, 15.6% of nurses expressed satisfaction in the insulin-dosing process compared with 69.2% postimplementation (P < .05). CONCLUSIONS: Implementation of an IDC reduced the average wait time in ordering and administration of rapid-acting insulin and improved nursing satisfaction with the process.