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

AIM: To assess compliance with paediatric empiric anti-infective guidelines and anti-infective drug dose table for children. METHOD: Data collection was carried out on the paediatric wards. EXCLUSIONS: ▸ Bone marrow transplant patients (BMT).▸ Patients not on empirical anti-infective treatmentData were collected prospectively between January and 30 February 2015. A data collection form was completed and data analysed using Excel. STANDARDS: (1) 90% adherence to the paediatric guidelines for empirical anti-infectives treatment(2) 90% prescriptions have the indication recorded in either the drug charts or notes(3) 90% prescriptions have duration recorded of treatment/review date on drug chart or medical notes(4) 95% initial doses should adhere to the anti-infective drug dose table for children RESULTS: Data were collected from 50 patients; eight were subsequently excluded as they were not on empirical treatment or were prescribed antibiotics started prior to admission giving a final sample for analysis of 42.40/41 prescriptions (98%) adhered to the paediatric guidelines for the empirical treatment prescribed. 1 of 41 prescriptions (2.4%) did not. EXCLUSION CRITERIA: One indication was not within guidelines ('abscess').40/42 prescriptions (95%) stated the indication for the anti-infective. 2 (5%) required prompting from the pharmacist. 14 out of 42 (33%) had the indication documented in the notes and 28 (67%) on the drug chart.26/42 prescriptions (62%) had a record of the duration of treatment/review date on the drug chart/notes. Of the 26 prescriptions with a recorded duration of treatment, 2 (8%) were found in the notes and 24 (92%) were found in the drug chart.67/69 (97%) of the initial doses adhered to the anti-infective drug dose table for children. 2 out of 69 (3%) did not. CONCLUSIONS: Standard 1 passed, this shows an improvement from the last audit of the guidelines in 2013 (of 72% adherence). In one case the indication of the antibiotic was not within the guidelines, which should be amended.Standard 2 passed-However, most of the indications were found in the notes, with clear documentation space on the drug chart it would be useful to have the indication in the drug chart. There has been a significant improvement from the previous audit carried out (from 16%).Standard 3 did not meet the adherence requirement expected. However, there has been an improvement from 14% from last year.Standard 4 (not been previously audited) suggests that the drug dosing table is also clear in providing guidance. Two data were excluded from the overall data as cefuroxime and rifampicin are not in the guidelines.Overall, the main need for improvement is having the duration of treatment documented. To achieve improvement in all standards would require:▸ Presenting the results to the antibiotic stewardship and pharmacy team.▸ Implementing an electronic prescribing system which prompts for completion of essential fields.▸ Updating and renewing the antibiotic Smart-phone App.▸ Compulsory education sessions for the junior doctors by the antibiotic stewardship team.

AN AUDIT OF WHETHER PRESCRIBED DOSES ARE MEASURABLE ON THE GRADUATIONS OF ONE ORAL SYRINGE.

AIM: In paediatrics drugs are prescribed as mg/kg doses to facilitate accurate dosing. Anecdotally, some drugs are prescribed in such a way that the volume to be given is difficult to measure which may lead to inaccuracies and potential for error. Locally, errors have been reported where there has been a misunderstanding of the required dose, especially when decimal points are involved. This audit aimed to evaluate doses prescribed for in-patient children and evaluate whether they can be measured using the printed markings of one oral syringe. METHOD: Data were collected for paediatric in-patients between 16th February and 27th March 2015 from paper drug charts and an electronic prescribing system depending which was in use in each area. Specific data on patient age, weight and prescribed dose were collected. Volumes were then calculated using the enteral products kept in the Trust formulary, including unlicensed specials. The prescribed volumes were reviewed against the Medicina Home® enteral syringes to see if they were measurable on the printed graduations of one oral syringe (in line with local dispensing standards). If they could not be measured, the percentage dose rounding required was calculated to see if doses could be rounded. A judgement was then made as to whether this was within an acceptable safe dose limit. RESULTS: Data for 560 individual medication orders for oral medicine were collected, 257 from electronic prescribing and 303 from paper charts. Of these 457 were liquid doses, 103 were from products only available as tablets or capsules. Of the 257 electronically prescribed doses, 61 (24%) were not measurable. Of the 303 paper chart doses, 57 (19%) were not measurable.Of the 457 liquid doses 77 only needed up to 4% dose adjustment to become measurable. A further 10 doses required up to 9% dose adjustment.Drugs that were frequently prescribed as non-measurable doses were: diazepam, alimemazine, chloral hydrate, azithromycin, metronidazole, paracetamol & ibuprofen.Some doses were not measurable from tablets and no liquid is available in the Trust: clonidine, omeprazole, lansoprazole, nifedipine SR.19/560 (3.4%) of medication orders required a dose to be measured to two decimal places: diazepam, morphine, clonazepam, furosemide, spironolactone, chloral hydrate, ranitidine, chlorothiazide, azithromycin, erythromycin. CONCLUSION: This audit has shown that by prescribing accurately as mg/kg without any dose rounding almost a quarter of doses cannot be measured accurately. Only a small dose adjustment is required to make the doses measurable. The current electronic prescribing system in use does not appear to have any automatic rounding, indeed the prevalence of difficult to measure doses was slightly worse (although not statistically significant, p value 0.19, Chi squared test), possibly because the prescriber doesn't "sense check" what they are prescribing as it is automated. Particular drugs with unusual strengths are often implicated in having harder to measure doses. Consideration should be made to round doses when prescribing and to add information regarding the strength of liquids available in local clinical guidelines.

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

AIM: To study which weight estimate calculation used in paediatric resuscitation results in optimal drug dosing; Advanced Paediatric and Life Support (APLS) or the UK Resuscitation Council age-based formula. METHOD: Commonly used drugs used in paediatric resuscitation were selected and a literature search conducted for each drug's pharmacokinetic properties, concentrating on the volume of distribution (Vd). Hydrophobic drugs have a higher Vd than hydrophilic drugs as they distribute preferentially to fat mass (FM). The larger the Vd, the higher the initial dose required to achieve therapeutic plasma concentrations. Actual body weight (ABW) estimates are a good indicator of Vd for hydrophobic drugs as they correlate well with FM. Ideal body weight (IBW) estimates may be a better indicator of Vd for hydrophilic drugs, as they correlate better with lean body mass. This highlights potential variation between ABW and IBW, which may result in toxic or sub-therapeutic dosing. RESULTS: The new APLS formulae give higher estimates of expected weight for a wider age range. This may be a more accurate reflection of ABW due to increasing prevalence of obesity in children. The UK Resuscitation Council's formula appears to result in a lower estimate of weight, which may relate more closely to IBW. CONCLUSION: The main drugs used in paediatric resuscitation are hydrophilic, thus the APLS formulae may result in too much being given. Therefore the UK Resuscitation Council's single formula may be preferred. In addition, a single formula may minimize error in the context of a child of unknown weight requiring administration of emergency resuscitation drugs.

The use of a consultant-led ward round checklist to improve paediatric prescribing: an interrupted time series study.

UNLABELLED: A Check and Correct checklist has previously been developed to increase feedback on prescribing quality and enhance physicians' focus on patients' drug charts during ward rounds. Our objective was to assess the impact of introducing such a prescribing checklist on the quality and safety of inpatient prescribing in two paediatric wards in a London teaching hospital. Between 15 March 2011 and 15 May 2011 (pre-intervention) and between 23 May 2011 and 23 July 2011 (post-intervention), we recorded rates of both technical prescription writing errors and clinical prescribing errors twice a week. During the pre-intervention period, the overall technical error rate was 10.8 % (95 % confidence interval 10.3 %-11.2 %); the clinical error rate was 4.7 % (3.4 %-6.6 %). The most common errors were absence of prescriber's contact details and dose omissions. After the implementation of Check and Correct, error rates were 7.3 % (6.9 %-7.8 %) and 5.5 % (3.9 %-7.9 %), respectively. Segmented regression analysis revealed a significant decrease of -5.0 % in the technical error rate (-7.1 to -2.9 %; -37.7 % relative decrease; R (2) = 0.604) following the intervention, independent of changes in overall medical records' documentation quality. Regarding clinical errors, no significant impact of the intervention could be detected. CONCLUSION: Implementing a Check and Correct checklist led to an improvement in the quality of prescription writing. Although a change in culture may be needed to maximise its potential, we would recommend its more widespread use and evaluation.

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

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

British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011.

The British Thoracic Society first published management guidelines for community acquired pneumonia in children in 2002 and covered available evidence to early 2000. These updated guidelines represent a review of new evidence since then and consensus clinical opinion where evidence was not found. This document incorporates material from the 2002 guidelines and supersedes the previous guideline document.

A clinical information system reduces medication errors in paediatric intensive care.

PURPOSE: To determine the effect of electronic prescribing (EP) with a clinical information system (Intellivue Clinical Information Portfolio, Philips, UK) on prescribing errors and omitted doses in a paediatric intensive care unit (PICU). METHODS: Prospective audit of prescribing errors and omitted doses for 96 h periods in three epochs: (1) before implementation of EP, (2) 1 week and (3) 6 months later. RESULTS: There was a non-significant reduction in prescribing errors: 8.8% (95% CI 4.4-13.2) pre-implementation of EP versus 8.1% (4.4-11.8) 1 week after implementation and 4.6% (2.0-7.2) 6 months later. The prevalence of omitted doses decreased significantly 6 months following implementation, changing from 8.1% (5.8-10.4) pre-implementation to 10.6% (6.5-14.7) 1 week after implementation and 1.4% (CI 0-2.8%) 6 months after implementation (P < 0.05). CONCLUSION: EP within a clinical information system increases medication safety in a PICU.