Authors (including presenting author) :
Yip YWC(1), Chan CCT(1), Wong SCM(2), Kan SHP(2), Chu MY(2), Lau CL(2), Lee WM(2), Au-Yeung KK(3), Leung T(2), HKWC ITIS(3), Chim S(2), Chui CMW(1)
Affiliation :
(1) Department of Pharmacy, Queen Mary Hospital
(2) Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital
(3) Information Technology and Information System (ITIS), Hong Kong West Cluster
Introduction :
Parenteral nutrition (PN) is an essential part of the medical management of critically-ill paediatric patients. Unlike standardized commercial preparations used in adults, PN formulations for neonates and infants are customized to meet individual nutritional requirements. Previously, hand-written PN prescriptions were prepared and sent to Pharmacy for compounding. Pharmacists from Total Parenteral Nutrition (TPN) Unit would review and verify the orders from both clinical and pharmaceutical perspectives. In-house data suggested approximately 50% prescriptions required clarifications and amendments, such as overdosage of calcium leading to calcium-phosphate precipitation and osmolarity being too high for peripheral infusion. Given the highly-complicated nature of PN regimen, PN ordering process is liable to medication errors, including complex weight-based calculations, illegible handwriting and communication breakdown among different parties. It is also time-consuming with back-and-forth amendments in prescriptions. Latest ESPGHAN/ESPEN/ESPR/CSPEN Guidelines strongly recommended that computerized prescription should be used in PN ordering process.
Objectives :
(1)Enhance safety and reduce medication errors in individualized PN ordering
(2)Revamp PN ordering logistics for effective and efficient communication channels
Methodology :
NICU, PICU and Clinical Pharmacists team collaborated to redesign the workflow of PN ordering, with implementation of electronic prescribing, paperless communication and an online PN calculator. Replacing hand-written paper prescriptions, Clinical Information System (CIS), which is a clinical communication platform in NICU and PICU, was revamped to allow electronic PN prescribing. Limitations were set for prescribing electrolyte content in PN to ensure proper dosage. Paediatric Clinical Pharmacists would clinically verify the orders on ward. CIS was accessible in Pharmacy so that TPN Pharmacists can instantly review the electronic prescriptions without facsimile or hardcopy delivery. Any amendments on the orders can be directly documented on CIS for efficient communications. Moreover, an online “Tailor-made TPN Calculator” was designed by Pharmacy, with support from the ITIS Department. By inputting the prescriptions, the Calculator would check for any compatibility and compounding issues. “Alert prompts” are in place when the doses of macronutrients and electrolytes are too high. Nutritional information like osmolarity, calories and glucose infusion rate are also available to aid clinical decisions.
Result & Outcome :
Electronic PN prescribing and paperless communication were implemented in 2021 and the “Tailor-made TPN Calculator” was launched in the Intranet in 2022. This project marks the multidisciplinary collaboration between Paediatricians, Clinical Pharmacists, CIS team and the ITIS Department, aiming to reduce the risk of medication errors, improve communication and enhance quality of care regarding PN use in this high-risk patient group.
