Archives of disease in childhood
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To evaluate clinical management of acute pain with respect to pain assessment, scoring and timing of analgesia and whether appropriate supportive medicines were prescribed alongside strong opiates. A previous pain audit found dosing of analgesia was appropriate but did not assess clinical management against pain scores. Our paediatric guideline does not currently stipulate guidance on appropriate time frames to administer analgesia and re-assess pain. Standards were developed with a multidisciplinary team to audit against. ⋯ Despite lack of guidance around timing of pain assessment and administration of drugs, pain scores were being recorded regularly and acted upon, although not within a structured time frame. Observation charts allowed for assessment of pain scores at 15-minute intervals but only 'on the hour' documentation were observed. Specific guidance around timing of analgesia administration and assessment will be introduced to the revised guideline with medical and nurse training sessions to standardise practice and improve management of pain, in addition to safe prescribing of opiates.
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All-cause infant and childhood mortality has decreased in the UK over the last 30 years. Advances in paediatric critical care have increased survival in paediatric intensive care units (PICUs) but may have affected how and when children die in PICU. We explored factors affecting length of stay (LOS) of children who died in PICU over an 11-year period. ⋯ Increased LOS in children who die in PICU is driven by a decreased proportion of early deaths and an increased proportion of late deaths. This trend, combined with an increase in the severity of illness in early deaths, is consistent with a reduction in early mortality for acutely ill children, but a prolongation of life for those children admitted to PICU with life-limiting illnesses.
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Clarity and accuracy of the pharmacy aspects of cancer clinical trial protocols is essential. Inconsistencies and ambiguities in protocols have the potential to delay research and jeopardise both patient safety and the collection of credible data. The Chemotherapy and Pharmacy Advisory Service (CPAS) was established in 2007 by the UK National Cancer Research Network, currently known as National Institute for Health Research Clinical Research Network, to improve the quality of pharmacy-related content in cancer clinical trial protocols. This abstract describes the scope of CPAS, its methodology of mandated protocol review and an analysis of the issues found and reported in paediatric oncology and haematology trials. ⋯ Review by CPAS of pharmacy content of paediatric oncology and haematology clinical trial protocols prior to final approval is feasible and exposes many undetected clinically relevant issues that could hinder efficient trial conduct and/or patient safety. This analysis has highlighted that the majority of suggestions were deemed clinically significant and effectively incorporated into the final protocols. The refinement of existing and development of further pharmacy-related guidance documents by CPAS might support more effective and safer clinical research.
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Prescription errors, including continuous infusion prescriptions are one major source of concern in the paediatric population. Evidence suggests that use of an electronic or web-based calculator could minimise these errors. In our paediatric critical care unit (PCCU) we have created an electronic continuous infusion prescription chart to target errors in this area and conducted an audit to assess its effect on error reduction. ⋯ The use of an electronic continuous infusion prescription chart has been successfully set up and used on PCCU. Its use has significantly reduced continuous infusion prescription error rates. The one error on electronic prescription charts was due to incorrect data input.Whilst similar formats exist for transferring patients between intensive care units in the UK, this differs by its use on inpatients. As a new project, various learning points were gained during the process. Some discrepancies in the formulas were identified during the validation process and trial period and the flexibility to change these quickly was paramount. The need to standardise prescribing habits and administration preferences was also important before proceeding to the formulation stage. Security and version control was another factor to consider ensuring restricted use of the most updated version.Major advantages of this prescription chart include ease of set up and low cost compared to established commercial programs. Another was the ability to quickly adapt information to the changing needs of the unit or updated dosage recommendations.In summary, the use of the electronic continuous infusion prescription chart has significantly reduced prescription error rates on PCCU. It has also allowed more efficient use of medical and pharmacy time resources.
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Local Guidelines for peri-operative pain management in children published in 2012 recommended that paracetamol dosing was calculated using ideal body weight (IBW) to prevent inadvertent overdosing in overweight and obese children.1 The purpose of this audit was to establish compliance with these guidelines. The oral paracetamol dose recommended was 20-30 mg/kg as a single dose then 15-20 mg/kg every 4-6 hrs with a maximum of 90 mg/kg/day. IV paracetamol doses were as recommended in BNF for Children (BNFC).2 BNFC states that paracetamol doses totalling 150 mg/kg may cause severe hepatocellular necrosis and renal tubular necrosis but the potential for adverse effects in some children can be seen with doses as little as 75 mg/kg in 24 hrs. ⋯ 100 inpatient prescriptions (71 elective and 29 non-elective) and 35 discharge prescriptions were analysed.1. Weight was annotated for 84% of inpatient prescriptions and 94% of discharge prescriptions; height was not documented for any patient. Therefore data was analysed basing IBW on 50th centile of the UK growth charts.2. The following results are based on IBW: ▸ Six inpatients prescribed oral paracetamol were classified as overweight or obese; doses ranged from 17.4-30 mg/kg/dose. ▸ Four patients prescribed IV paracetamol were classified as overweight or obese; doses ranged from 20-23 mg/kg/dose. ▸ Four patients prescribed the combined route of PO/IV paracetamol were classified as overweight or obese; doses ranged from 18-24 mg/kg/dose. ▸ Six patients prescribed oral paracetamol on discharge were classified as overweight or obese; doses ranged from 13-33 mg/kg/dose.3. Paracetamol was prescribed as IV/PO in 32 inpatients.4. IV paracetamol was prescribed in 52 patients; 20 were not reviewed at 48 hrs for a switch to oral route. Of these, only 3 were appropriate prolonged IV prescriptions.Conclusion Audit findings showed inadequate compliance with local prescribing guidelines posing a risk of inappropriately high doses of paracetamol being prescribed to overweight and obese children. In addition, unnecessarily prolonged IV use was observed. Following feedback local guidelines were amended in 2015 to recommend that in obese children, dosing should reflect lean body mass and ideal weight for height. The maximum daily dose was also reduced to 75 mg/kg/day. Prescribers require education regarding this important issue.