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P37 Medicines optimisation for children with complex medical issues: a cross-sector approach
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  1. Helen Cooper,
  2. Sheatha Abumehdi
  1. Evelina London Children’s Hospital

Abstract

Problem encountered Polypharmacy is a well-recognised issue in children with complex medical issues. Such children are often seen by a variety of professionals across the healthcare interface. The majority of these patients have an enteral feeding tube and consequently are routinely prescribed liquid medicines; some unlicensed, some non-formulary and some high cost.1

In our local integrated care system (ICS) there is a lack of awareness of formulations and liquid concentrations recommended in the Paediatric Formulary by healthcare professionals. While procurement is more tightly controlled in the hospital setting, GP prescribing systems list vast numbers of different formulations and concentrations with little inbuilt guidance on local or national recommendations. Clinical appropriateness and medicine safety often rely on primary care prescribers reviewing what was prescribed previously, checking what is usually given with the patient or carer, and liaising with the community pharmacist on available formulations.2

Routine medication reviews for adults in primary care are well established, with use of the Discharge Medicines Service in community pharmacies becoming common practice. Barriers to medication reviews for paediatric patients in primary care include lack of paediatric-specific medicines knowledge, unawareness of available resources, time pressures and staffing pressures. Primary care prescribers may understandably be reluctant to change a child’s medication to a recommended formulation or concentration without advice from a specialist. Patients and carers may feel anxious about proposed changes and want reassurance from a specialist. Communication barriers between primary care prescribers and specialist teams may limit information sharing.

How the pharmacy team contributed Specialist paediatric pharmacists (SPPs) based in a large paediatric teaching hospital were funded by the local ICS to standardise and rationalise prescribing of medicines to children, focusing on unlicensed specials. Complex paediatric patients and the barriers to optimising their medicines were brought to the SPPs through virtual meetings and e-mail communications with primary care prescribers.

SPPs coordinated medication reviews for these patients, including sourcing GP repeat lists, obtaining recent and relevant clinic letters and contacting named specialist consultant(s). SPPs made recommendations on prescribing optimisations and changes in line with the Paediatric Formulary. SPPs harmonised decision-making processes between healthcare professionals involved in patient care across the interface to agree appropriate changes. GPs and primary care pharmacists were provided with information and resources to appropriately communicate changes to patients or carers and were supported by SPPs during this process.

Key examples include: dihydrocodeine for acute, short-term pain stopped, midazolam for seizure control changed from unlicensed liquid special to licensed pre-filled syringe, clonidine and gabapentin unlicensed liquids changed to licensed liquids, phenobarbital, glycopyrronium and clobazam liquids optimised to standardised concentration.

Outcome and Lessons Learned 9 patients over a 2-month period had their medicines reviewed and optimised using this multi-disciplinary cross-sector approach. Associated cost savings were tracked and reported. This work highlights that continued improvements are needed to facilitate communications between specialist hospital-based clinicians and non-specialist primary care clinicians. SPPs offer significant value in providing an interface link between primary and secondary care to identify, recommend and safely initiate changes to prescribed medicines for children.

References

  1. Conn R, Fox A, Carrington A, et al. Prescribing errors in children: why they happen and how to prevent them. Pharmaceutical Journal 2023;310:7973.

  2. O’Hare A. Patient safety spotlight: the risks of prescribing and supplying medicines to children. Regulate: 2021 https://www.pharmacyregulation.org/regulate/article/patient-safety-spotlight-risks-prescribing-and-supplying-medicines-children

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