Incidence of Medication-Related Problems Following Pediatric Epilepsy Admissions

Prescribing errors in hospitalized patients on the ketogenic diet

PURPOSE

A ketogenic diet (KD) is recommended as a nonpharmacological treatment option in pediatric patients with epilepsy. Prescribing errors for these patients can result in inadvertent carbohydrate exposure, increasing the risk of loss of ketosis and breakthrough seizures. The objective of this study was to evaluate the incidence of inadvertent carbohydrate exposure in hospitalized children on the traditional KD.

METHODS

This was a retrospective cohort study of patients with epilepsy receiving KD therapy while admitted to the hospital. Patients 18 years of age or younger diagnosed with epilepsy and/or intractable epilepsy, receiving antiseizure medications on the traditional KD or KD total parenteral nutrition, or with GLUT-1 genetic disorder were included. The primary endpoint was the incidence of patient admissions with unintended orders for carbohydrate-containing medications during hospitalization.

RESULTS

A total of 42 patients accounting for 66 inpatient admissions were included in this study. The total incidence of admissions with an inadvertent carbohydrate-containing medication order placed was 52% for intravenous (IV) medications and 64% for oral medications. Patients averaged 2 carbohydrate-containing orders per admission for both IV and oral medications. The most commonly prescribed carbohydrate-containing medications were given at least once before being discontinued. Of the IV medications documented in this study, 6 were premix products diluted in carbohydrate-containing solutions and did not have an alternative file built to facilitate dilution in normal saline.

CONCLUSION

Because of their restricted carbohydrate allowance and the possibility of carbohydrate-containing product excipients, patients on the KD are at increased risk for receiving inappropriate carbohydrate-containing medications during hospital admissions.

Seize the day: A quality improvement approach to support transition of care and decrease 30-day readmissions for pediatric patients with epilepsy

PURPOSE

Elevated rates of 30-day readmission for children with epilepsy were noted at a stand-alone pediatric acute care facility. To address this issue, a standardized pathway was created and implemented in 2017. The main objective was to ensure that patients with epilepsy and their families were adequately prepared for discharge and the transition to home.

DESIGN AND METHODS

Using a quality improvement (QI) approach, a standardized education pathway was developed and implemented to decrease unplanned 30-day readmissions of patients with a diagnosis of epilepsy from a specialized neurology unit. An interprofessional care team received training to ensure standardized communication around the pathway approach and components. All patients with a diagnosis of epilepsy and their families were educated using the pathway and guided through additional simulation and teach-back exercises.

RESULTS

Analysis demonstrated a 27.6 % decrease in unplanned 30-day readmissions in the 6 years following implementation. An estimated $950,000 in cost savings was achieved secondary to program implementation.

CONCLUSIONS

Utilizing the pathway standardizes epilepsy management education and decreases unplanned 30-day readmissions for pediatric patients diagnosed with epilepsy. A standardized educational plan is an essential component of patient discharge teaching and proper home management of epilepsy.

PRACTICE IMPLICATIONS

For sustainability, education needs to be continuously refreshed and included in onboarding new nurses. To ensure health equity, translation of the pathway into multiple languages is needed.

Evaluation of a Pharmacist-Driven Discharge Medication Reconciliation Service Pilot at a Children's Hospital

OBJECTIVE

The purpose of this study was to evaluate the feasibility of a pharmacist-driven discharge medication reconciliation (DMR) service at our children's hospital by completing a 2-week pilot on a general pediatrics unit.

METHODS

This was a prospective study and included patients discharged during pilot hours whose DMR was completed by the pharmacist. The primary outcome was evaluation of time required for a pharmacist to complete the DMR. Secondary outcomes included classification of pharmacist interventions made and their associated cost-avoidance, medication-related problems reported within 14 days of discharge, hospital readmission due to medication problems within 30 days of discharge, and medical resident satisfaction assessed via prepilot and postpilot surveys.

RESULTS

A total of 67 patients had their DMR completed by a pharmacist during the pilot. The pharmacist spent an average of 30 minutes completing each DMR, although this was variable, as evidenced by an SD of 36.4 minutes. Pharmacists documented 89 total interventions during the study period. The most common intervention types were therapeutic optimization (32.6%) and modification of directions (29.2%). Total estimated cost-avoidance during the study pilot was $84,048.01. For the pilot population, 1 medication-related problem was identified within 14 days of discharge. There were no medication-related readmissions identified. Medical residents reported increased confidence that the DMR was completed accurately and satisfaction with the DMR process during the pilot compared with before the pilot.

CONCLUSIONS

Implementing a pharmacist discharge medication service requires consideration of -pharmacist time and salary, which may be offset by cost-avoidance.

Reducing Discharge Medication Reconciliation Errors at a Pediatric Neurology Inpatient Unit

Background and Objectives

Medication reconciliation errors are a common problem in health care, particularly during transitions of care. Discharge medication reconciliation (DMR) errors in a pediatric setting can range from 26% to 42.2%. We conducted a quality improvement project to decrease DMR error rate at Dayton Children's Hospital in Dayton, Ohio.

Methods

We conducted 2 interventions, each with 3 Plan-Do-Study-Act cycles from September 2021 through February 2023. The first intervention focused on using current specialty neurology nurses as scribes and creating a template note to include the plan of care and review of DMR before discharge. Our second intervention consisted of standardizing the seizure rescue medication order by creating an order panel within our electronic medical record system for all the rescue medications presently available. Medication errors were documented by the specialty neurology nurse during a phone conversation on the next business day post discharge. DMR error rates were calculated for each week using a control chart. Medication errors and patient harm were classified according to the National Coordinating Council for Medication Error Reporting and Prevention Index.

Results

One hundred six errors were noted. Of these, 98 (92%) occurred in patients with seizure and 64 (60%) were related to prescription of seizure rescue medication specifically. The baseline error rate was calculated at 15.7% or 7 errors per month (January 2021 through June 2021). The average error rate dropped from 15.7% to 5.3% (2 errors per month) after initiation of our first intervention (September 2021). Twelve weeks after initiation of the second intervention, a 2.9% (1 error per month) was noted. Afterward, there was a ten-week period of 0% errors.

Discussion

Sustainable reduction of DMR errors in pediatric patients with epilepsy was achieved by using specialty neurology nurses to scribe the care plan and creating order panels to facilitate accuracy of discharge medication orders without additional cost to the hospital.

Building a pediatric neurocritical care program: The role of the clinical pharmacist practitioner on clinical practice and education. A curriculum for neuropharmacology training

Clinical pharmacists are a part of the integrated health care team and provide valuable input on medication management for patients with acute and chronic disease states. Using epilepsy as a model, pharmacist involvement in patient care has been associated with significant reductions in monthly seizure frequency. Given differences in etiology, pediatric patients with epilepsy are likely to have higher number of treatments, with additional pharmacodynamic and pharmacokinetic differences, adding to the importance of utilizing a pediatric clinical pharmacist practitioner with neuropharmacology expertise. There is an increasing exposure to critically ill patients with epilepsy and other neurological disorders in the pediatric intensive care unit (PICU). These patients are more medically complex, increasing the risk for medication errors and increased health care costs. Emphasis on neurocritical care education is a vital component to improving patient outcomes. Inclusion of a clinical pharmacist practitioner in these settings yields a positive impact on major health outcomes. In 2018, the Neurocritical Care Society developed consensus recommendations on the standards for the development of adult neurocritical care units. A pharmacist-delivered pediatric critical care neuropharmacology rotation represents a novel approach to expanding physician education to improve patient outcomes. While there are sparse publications highlighting the importance of adult critical care and NCC pharmacists, no such literature exists describing the benefits of pediatric neurocritical care (PNCC) pharmacists. To the best of our knowledge, this is the first manuscript describing the role of clinical pharmacist practitioners in the development of PNCC program and the benefits they provide to patient care and education.