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AimTo audit the prescribing and monitoring of vancomycin in the neonatal units against the local guideline.The neonatal vancomycin guideline has never been audited. Anecdotally, prescribing and monitoring of this drug is challenging, with pharmacists frequently being asked for advice. The guideline has two ranges depending on which bacteria are being treated, 10–15 mg/L and 15–20 mg/L.The initial dosing frequency is different for babies greater than 10 days of age.MethodData on vancomycin doses, levels, time taken, patient age, weight and renal function, were collected on a data collection form prospectively, from prescriptions and clinical records for all babies on vancomycin on between 17/10/2016 and 16/12/2016. Patients were followed throughout their stay; some had repeated courses. The audit was approved locally. Audit standards were derived from the guideline, with 100% adherence aimed for.Data were entered onto an Excel spreadsheet.ResultsData was collected from 19 patients, 28 vancomycin courses and 31 vancomycin levels.28/28 (100%) prescriptions had the correct initial dose. In one neonate the dose changed from 12 to 8 hourly when they were 10 days old. This change led to a high level.13/15 (87%) had the level taken at the correct time. Two were taken 2–3 hours late. Thirteen courses were stopped before requiring levels.19/31 levels (62%) were within a safe range (10–20 mg/L).All 6 levels>20 mg/L had the next dose held and the level repeated. In two of these cases there was no subsequent dose reduction causing further high levels. In one case a further vancomycin course was prescribed as per guidelines, with no consideration of previous levels, a high level was recorded again.Two levels between 15–20 mg/L were considered too high; a dose was omitted, resulting in two sub-therapeutic levels (below 10 mg/L).Of the other four low levels, three were not acted upon appropriately – no dose or frequency increase, one was acted on correctly with a dose increase.ConclusionThe size of the data set was small but the descriptive findings are interesting.The initial aspects of the guideline are adhered to with all doses prescribed correctly. High levels resulted in doses being held and levels repeated but subsequent actions were suboptimal. Levels appeared to be viewed in isolation and so either no change or an incorrect change was made causing further avoidable high levels. Often low levels were not acted upon appropriately.It is possible that there is limited understanding of pharmacokinetic principles underpinning the adjustment of doses.Changes have been made to the guidelines including a statement that the doses are the initial starting doses only and that dose adjustments are based on levels not age. The different ranges caused confusion and given that the specific bacteria presentmay not be known when initiating treatment, the guidelines have been amended to clarify the safe range of vancomycin to be 10–20 mg/L. Teaching sessions with worked examples will be held with all prescribers and nursing staff.

AimTo design, build and implement Cerner EPMA for all drugs and infusions required in neonatal units across a regional Integrated Care Service (ICS).SituationThe ICS comprises four NHS Trusts, two of which already shared the Cerner domain with the remaining trusts joining in autumn 2023. Cerner was in use in adult and paediatric areas, with neonatal units the last to join due to complexities of prescribing. The multi-disciplinary approach from all four trusts included nurses, consultants and pharmacy (EPMA and Women and Children’s). The teams collaborated over an 18 month period in order to align prescribing practices and to design and build neonatal medication order sentences, powerplans for continuous infusions (such as inotropes and sedation), intravenous fluids and parenteral nutrition.Key prescribing guidelines were shared between trusts and the teams worked together to identify and harmonise differences in local practice. The trusts use the ‘standard flow rate, variable concentration’ system of prescribing drug infusions, some with different calculation ‘factors’. Sharing the Cerner domain required alignment of these. All sites were prepared to make changes. One site used both 25 mL and 50 mL syringe volumes (depending on weight). However, this contributed to variation in practice and it was agreed to use the 25 mL volume, with the benefit of reducing drug wastage in certain situations.Stakeholders from the two trusts with level 3 neonatal units, (already live with adults and paediatrics), met in person in late spring 2021 to harbour professional relationships that continued to develop through virtual collaborative working on Microsoft Teams®. One senior pharmacist had experience of working at both trusts, further strengthening collaboration.Sharing the Cerner domain between four trusts and six neonatal units required compromise. The neonatal medicine build was standardised but as with the adult and paediatric build, excluded dose range checking and no guidelines were embedded. Optimisation of the existing Cerner build for paediatrics included adding order sentences for many drugs with options for neonatal ‘units of measure’ (such as micrograms) and ‘frequencies’. Governance around each build was approved from representatives of all disciplines from each trust.The neonatal medications build involved creation of approximately 200 new order sentences and 30 specific neonatal intensive care unit (NICU) ‘powerplans’ (for example, continuous variable rate infusions specifying dose range, concentration and diluents).Continuous variable rate infusions allow the weight-based dose to be prescribed in a choice of diluents as well as documentation of dose (rate) changes (x-y microgram/kg/hour or minute) without a new prescription which reflects previous practice on paper.In autumn 2022, the two trusts already sharing the Cerner domain went live with EPMA on all four neonatal units with the rest of the region joining in autumn 2023. ConclusionThe successful implementation of a complex Cerner EPMA neonatal build, with complexities and intricacies of level 3 neonatal unit settings, as well as level 1 and 2 units was attributed to successful stakeholder engagement, multidisciplinary collaborative working and negotiation. The benefits of sharing a Cerner domain should lead to greater standardisation of care across the ICS.

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 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.

AimTo assess compliance with paediatric empiric anti-infective guidelines and anti-infective drug dose table for children.MethodData 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 childrenResultsData 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.ConclusionsStandard 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.

AimIn 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.MethodData 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.ResultsData 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.ConclusionThis 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.

AimTo audit the quality of sedation prior to procedures and identify reasons for ineffective sedation.MethodAll paediatric patients (excluding intensive care) at Hospital X receiving pharmacological pre-procedural sedation were included. The sedation guideline had been recently updated but anecdotally the old guideline was being followed due to perceived sedation failures when following the new guideline. Staff nurses and ward pharmacists were asked to refer patients for the audit using a referral form. A poster was displayed in drug treatment rooms and labels attached to sedative medication to remind nurses to refer any suitable patients for the audit. Patients were also identified by looking in the ward diary for scheduled procedures. Data were collected on the day of the procedure, over a period of seven weeks (6th Jan to 21st Feb 2014) using a piloted data collection form. Data were analysed using Microsoft Excel based on drug and dose used, sedation success or failure, and on which guideline was followed.Standards:New guideline followed (Target 90%)Old guideline followed (Target <10%)Correct drug used (Target 100%)Correct dose used (Target 100%)Effective sedation (procedure could take place) (Target 90%)Results:12 patients were identified and included in the analysis.The new guideline was adhered to in 7/12 (58%) of cases.11/12 (92%) of patients received the correct drug and 8/12 (75%) received the correct dose according to the new guideline.Effective sedation was achieved on time in 7/12 (58%) of patients. In 3/12 (25%) of cases the procedure was delayed, taking place later the same day following a second dose of chloral hydrate 50 mg/kg.2/12 (17%) of cases failed sedation and the procedure had to be re-scheduled under general anaesthesia.Four patients were given chloral hydrate 100 mg/kg, all were succesfully sedated. Chloral hydrate 50 mg/kg in combination with alimemazine 2 mg/kg achieved effective sedation in only 1/2 (50%) of patients, however one of the children receiving this combination weighed 16 kg and according to the new guideline should have received midazolam (0.5 mg/kg orally or 0.2–0.4 mg/kg intranasally). The least successful sedative was chloral hydrate at a dose of 50 mg/kg, with only a 1/4 (25%) success rate. This dose does not feature in the new guideline and should therefore never be used as a single agent. Only two patients were given midazolam, one of which (intranasal 0.33 mg/kg) resulted in successful sedation. The other, an oral dose (0.5 mg/kg) failed.ConclusionThe sample size was small but chloral hydrate 50 mg/kg appears to be an ineffective dose. Patients <15 kg should be prescribed either 100 mg/kg or co-prescribed chloral hydrate 50 mg/kg and alimemazine 2 mg/kg. Further local data are required regarding the effectiveness of midazolam.The results do not necessitate a change in the current guideline, as procedures carried out according to the guideline were successful in the majority of cases, but rather a change in practice to reflect the guidance. Prescribers need to be made aware of the correct chloral hydrate dose and non-adherence to recommended practice.

BackgroundAnti-NMDAR encephalitis is one of the commonest known types of autoimmune encephalitis with an increasing recognition in the paediatric population.1 2 It is characterised by abnormal behavioural and cognitive symptoms, seizures and movement disorders where treatment failure or failure to treat can result in long term disabilities or mortality.1A 4-year-old patient with a background of autism was admitted to the paediatric intensive care unit (PICU) due to encephalitis with convulsive status epilepticus where he remained intubated for 22 days and was later diagnosed with anti-NMDAR encephalitis. The patient had persistent abnormal choreoathetoid movements and intermittent seizures despite multiple anti-epileptics, two courses of corticosteroids, two courses of intravenous immunoglobulin, two cycles (10 sessions per cycle) of plasmapheresis and a course of weekly rituximab. Due to the lack of response from these initial pharmacological interventions, the use of cyclophosphamide and mycophenolate mofetil was considered. Cyclophosphamide and mycophenolate mofetil inhibits the proliferations of B- and T-lymphocytes3 4 which acts as the basis of its immunosuppressive actions. However, available evidence on the dosing and monitoring information in the paediatric population for this unlicensed indication is limited.Pharmacy ContributionsAfter discussion with the multi-disciplinary team (MDT) with extensive input from the paediatric neurologist, a literature search was conducted to determine an appropriate dosing regimen. As this was an off-label use, the paediatric neurologist and the attending consultant took clinical responsibility. Intravenous cyclophosphamide was started at 750 mg/m2 once a month for three cycles and oral mycophenolate mofetil was started at 600 mg/m2 twice a day as maintenance therapy a week after. The specialist pharmacist explained the individualised treatment plan for the patient to the MDT and ensured measures (hydration and mesna) for the prevention of cyclophosphamide-induced haemorrhagic cystitis were appropriately prescribed on the electronic prescribing system with the appropriate timings of administration. Monitoring parameters to determine adverse effects were closely observed. A local guideline was developed during the treatment cycles to ensure all members of the MDT were following the correct procedures.OutcomeThe patient responded to cyclophosphamide and clinically improved after the completion of three cycles of monthly treatment. Maintenance mycophenolate mofetil was subsequently stopped a month after the last cycle of cyclophosphamide due to neutropenia. A review of the patient one year after first presentation shows the patient is almost back to their baseline.Lessons LearnedAlthough there are potentially serious side effects, cyclophosphamide and mycophenolate mofetil has been successful in the treatment of anti-NMDAR encephalitis. The recovery of this patient required extensive support from the entire MDT.ReferencesNHS England. Clinical Commissioning Policy: Rituximab for second line treatment for anti-NMDAR autoimmune encephalitis (all ages). March 2018.Salvucci A, Devine IM, Hammond D, et al. Pediatric anti-NMDA (N-methyl D-Aspartate) receptor encephalitis. Pediatric Neurology 2014;50:507–510.Summary of Product Characteristics. Cyclophosphamide 1000 mg Powder for Solution for Injection or Infusion. Last updated on eMC on 27-Jun-2017. Available at https://www.medicines.org.uk/emc/product/3525/smpc# [Accessed 04 July 2019]Summary of Product Characteristics. CellCept 1 g/5 mL powder for oral suspension. Last updated on eMC on 16-Mar-2018. Available at https://www.medicines.org.uk/emc/product/1569/smpc [Accessed 04 July 2019]

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.

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.