P11 Adaptation and implementation of standardised concentrations and guardrails technology in paediatric intensive care
Authors: Gandhi Henal , Rogers Naomi , Tugwell Stephen , Eftychiou Linda , Briar Charlotte , Zizkova Eva , Makhecha Sukeshi 
Published: April 2023

Context

Implementation of standardised concentrations of continuous infusions (SCCI) in paediatrics and guardrails technology on smart pumps significantly reduces medication errors and improves patient safety.1–3There is a national drive to implement SCCI coupled with guardrails technology on smart pumps, driven by the Neonatal and Paediatric Pharmacists Group (NPPG) and Royal College of Paediatrics and Child Health (RCPCH).2 3The merger of two specialist paediatric hospitals prompted alignment of governance processes, of which SCCI implementation across the organisation was key. This article focuses on Hospital B’s experience of implementing SCCI and guardrails, utilizing resources from Hospital A, who implemented in 2018.3

Methods

A team led by pharmacists was convened to lead this quality improvement initiative, linking with Hospital A, to obtain resources including the guardrails library (dataset) and learning from their experience. Hospital B’s pharmacists engaged with key stakeholders within paediatrics including a consultant, nurse educator, QI lead nurse and bedside nurse, to review, adapt and validate the library to suit their patient cohort. Plan Do Study Act cycles were used to continuously improve the process of implementation. A staff education session was conducted, outlining the importance and use of SCCI and guardrails.

Results

The dataset obtained from Hospital A required some adaptation across 49 drugs; 18 drugs were removed as not routinely used at Hospital B. 71% (22/31) of the adapted standard concentrations were similar whilst 29% (9/31) were amended.

100% of the dataset underwent changes, mostly minor; 12 drugs had units amended whilst 28 of the default doses, 18 of the soft minimum doses, 20 of the soft maximum doses and 23 of the hard max doses were amended.

Rationale for these changes include a slightly different patient cohort in Hospital B; mainly with fluid restriction in patients post-surgery requiring higher doses of sedation and inotropes. Additionally, the SCCI were tailored in line with guidelines, available formulations/strengths such as ready-to-use esmolol and to the adult cohort to aid familiarity, facilitating cross-working between adult and paediatric wards. And for guardrails, minimum or default doses were reduced to enable the lowest dose to be given whilst maximum doses were increased. All changes were to align to guidelines, BNFc or local practice. Unit changes were made to ensure familiarity.

Conclusions and Lessons Learned

In conclusion ‘one size does not fit all’ and using a dataset without adapting it to context poses safety risks. Adaptation of datasets by individuals tailored to local practice and patient cohort is key for successful and safe implementation. This is aligned with the evidence translation literature, which recognises that adoption of changes is complex and context dependent.4

Key learning points include engagement of key stakeholders is essential to ensure good communication and buy-in. Tailoring of datasets to meet patient needs is vital; considering PDSA cycles and the test, learn and scale up approach. Comprehensive education and training is crucial to ensure correct utilisation and safety, particularly as implementing changes poses increased risk of medication errors.

References

Royal College of Paediatrics and Child’s Health, Standardising intravenous infusion concentrations for children in the UK, April 2021, Pages 1 -12 https://www.rcpch.ac.uk/sites/default/files/2021-05/Standard Infusions JMC Paper v0.2.pdf

National Patient Safety Agency, Patient Safety Alert, March 2007, pages 1–12. https://healthcareea.vctms.co.uk/assets/content/9652/4759/content/injectable.pdf

Joanne Perkins, Virginia Aguado-Lorenzo, Sara Arenas-Lopez, Standard concentration infusions in paediatric intensive care: the clinical approach.Journal of Pharmacy and Pharmacology2017;69:537–543. https://doi.org/10.1111/jphp.12604

Reed JE, Howe C, Doyle C,et al. Simple rules for evidence translation in complex systems: a qualitative study.BMC Med2018;16:92. https://doi.org/10.1186/s12916-018-1076-9