OVERSEAS PEDIATRIC CLINICAL PHARMACY TRAINING AND PEDIATRIC CLINICAL PHARMACY SERVICE IN PRINCESS MARGARET HOSPITAL

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1 OVERSEAS PEDIATRIC CLINICAL PHARMACY TRAINING AND PEDIATRIC CLINICAL PHARMACY SERVICE IN PRINCESS MARGARET HOSPITAL Candy Lau Pharmacist Princess Margaret Hospital

2 CONTENT Overseas Training at University of Illinois at Chicago (UIC) Medical Centre Pediatric Clinical Pharmacy Service at Princess Margaret Hospital

3 TRAINING AT UIC 2 pharmacists selected Pediatric clinical pharmacy training A 3-month training General Pediatrics Neonatal Intensive Care Unit (NICU) Pediatric Intensive Care Unit (PICU)

4 TRAINING SITE University of Illinois at Chicago (UIC) Medical Centre Teaching hospital of University of Illinois at Chicago 34 pediatric, 12 PICU, and 55 NICU beds

5 TRAINING CONTENT -DAILY ACTIVITIES Attach with clinical pharmacist to attend ward round with multidisciplinary team Neonatologists, pharmacists, nurse practitioners, respiratory therapists, dietitian, social worker, & registered nurses

6 TRAINING CONTENT -DAILY ACTIVITIES Case review Review cases seen in morning round Discuss medication treatment options, monitoring, care plan with preceptors

7 TRAINING CONTENT -WEEKLY ACTIVITY Out-patient clinic visit Check patient s lab data Interview patient See patient with doctor Propose intervention to doctor Prepare patient medication list Provide patient counseling

8 TRAINING CONTENT -OTHERS Visit to central pharmacy and aseptic suite

9 THINGS LEARNT Total Parenteral Nutrition prescription Nutrition and fluid requirement of neonates Monitoring parameters Conditions require modification of TPN Therapeutic drug monitoring Different pharmacokinetics of premature infants Handling out of therapeutic range Patient interviewing and counseling Drugs commonly used in pediatrics Promote medication safety Medication reconciliation

10 PEDIATRIC CLINICAL PHARMACY SERVICE Back from training

11 PEDIATRIC CLINICAL PHARMACY SERVICE Service provided since June, 2011 Serves NICU and SCBU patients NICU: 14 beds SCBU: 25 beds

12 OBJECTIVES To improve medication safety and provide better pharmaceutical care to the patients through pediatric clinical pharmacy service

13 CLINICAL PHARMACY SERVICE Monday to Sunday Ward-round with doctors Case discussion Provide drug treatment options Provide interventions Clinical screening of medication orders Evaluate medication regimen MAR transcription checking Drug administration checking

14 CLINICAL PHARMACY SERVICE TPN consult and review Monitoring electrolytes, fluid balance, triglyceride Individualize nutrition need Recommendations for special medical conditions Review compatibility with drug infusions Drug information service Literature search Consolidate drug information Provide up-to-date drug information to doctors and nurses

15 CLINICAL PHARMACY SERVICE Protocols and guidelines development Retinopathy of prematurity sedation protocol Drug reference charts compilation Dosage reference charts Compatibility charts Pharmacokinetics consult and Therapeutic Drug Monitoring Time of sampling Pharmacokinetic calculations and interpretation

16 CLINICAL PHARMACY SERVICE Medication Management Service Ensure safe storage and administration of medications on ward Provide advice on storage of high-risk, look-alike, soundalike medications Pharmacy Intravenous Admixture Service (PIVAS) Drug cart management Ward stock management

17 WORKLOAD STATISTICS Over the 18-month period Medications for 18,305 patient days reviewed 22,008 medication orders screened 4,394 TPN orders reviewed 166 pieces of drug information provided

18 MEDICATION INCIDENT PREVENTION near miss per neonatal-activity-days prevented Before Clinical Pharmacy Service After Clinical Pharmacy Service 7 28

19 MEDICATION INCIDENT PREVENTION- INTERVENTIONS 352 interventions documented Interventions 17% 3% 6% 28% TPN Regimen(Dose, Freq, Route) Drugs to be added/discontinued Monitoring 3% Vaccination 16% 27% Dilution and Administration Others

20 MEDICATION INCIDENT PREVENTION Patient transferred in after partial resection of small bowel due to necrotizing enteral colitis Before transfer, patient was receiving partial TPN (1/2 bag) which delivers 3mmol/kg/day of potassium. The whole bag contains 6mmol/kg/day of potassium. Double dose of potassium in new TPN Risk of hyperkalemia Due to fluid restriction, doctor ordered TPN with same content but less fluid and intended to give full TPN to the patient. If not prevented, medication incident with severity index 3 Severity Index 0: Incident occurred but stopped before reaching patient. No consequence. 1: Incident occurred (reached patient) but no injury sustained. 2: Minor injury 3: Temporary morbidity 5: Major permanent loss of function/disability 4: Significant morbidity 6: Death

21 MEDICATION INCIDENT PREVENTION Morphine infusion of initial dose 10mcg/kg/hr was intended to be ordered by doctor Dilution calculation problem occurred, 20mcg/kg/hr was prescribed On dosage checking, discrepancy found before drug was administered Dose doubled Increased risk of respiratory depression, hypotension If not prevented, medication incident with severity index 3

22 MEDICATION INCIDENT PREVENTION NICU Infusion Calculator

23 MEDICATION INCIDENT PREVENTION Neonate found to have DVT Rare disease in neonates Tinzaparin chosen by doctors Information from pharmacist 1. Tinzaparin contains benzyl alcohol not suitable for neonates 2. Enoxaparin suggested as alternative 3. Dosage regimen, administration method, monitoring plan provided to doctor 4. Method of administration and dilution of Enoxaparin from prefilled syringe provided to nurse

24 MEDICATION INCIDENTS None during operation hours of clinical pharmacy service 11 occurred during non-operation hours 9 discovered by clinical pharmacist during medication order screening 7 dose omissions 1 transcription error 1 wrong dose

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26 BENEFIT OF PEDIATRIC CLINICAL PHARMACY SERVICE Improve medication safety Prevent prescribing errors Prevent incompatibility of medications Prevent drug interactions Ensure proper administration of medications Optimize drug treatment for patients Minimize side effects of medications Ensure efficacy and safety through therapeutic drug monitoring Improve nutrition support from TPN Optimize drug dosage and frequency according to changing pharmacokinetics of growing baby Build up trustable relationship with doctors and nurses

27 THANK YOU!