Setting

This study was conducted at a 170-bed university-affiliated tertiary paediatric hospital in Sydney, New South Wales. The hospital employs JMOs with two or more years of post-registration experience that may or may not include prior paediatric experience. During their employment, JMOs may be based onsite at the tertiary hospital or seconded to one of 23 different paediatric sites across New South Wales, Australian Capital Territory and the Northern Territory.

Orientation is mandatory for JMOs and includes attendance at a face-to-face AMS and safe prescribing session designed by medical and pharmacy staff. The session reinforces aspects of safe prescribing in children, introduces local practice expectations and includes demonstrations of how to access local medication-related resources. The information is also summarised in the hospital’s Junior Medical Staff Handbook. The Handbook is updated annually and lists frequently used guidelines, prescribing “tips” and prescriber responsibilities. The responsibilities include obtaining approval for the use of restricted antimicrobials according to the hospital’s computerised clinical decision support and approval system (CDSS, Guidance MS, Melbourne, Australia) as part of the local AMS policy. Technical training on the use of the CDSS has been in place since its implementation in 2012 and is addressed during a separate face-to-face session.

Since 2015, the time allocated for the safe prescribing session has been extended annually in order to cover broader aspects of paediatric medication use from the point of admission to discharge with a focus on antimicrobial use. However, JMO’s baseline knowledge and participation had never been formally assessed.

AMS and safe prescribing session and survey

JMOs who were employed by the hospital and working on site in the week before the start of term 1, 2017 (6 February 2017) attended one of two abridged face-to-face orientation programs that each included a 40 minute AMS and safe prescribing session. JMOs who had spent the previous 3-month term in another facility attended a longer face-to-face orientation program with a 60 minute AMS and safe prescribing session.

Presentation content and survey questions were designed by paediatric pharmacists with experience in quality use of medicines, medication safety and AMS. Content was finalised after feedback was received from: a consultant paediatrician responsible for general paediatric training, the hospital’s chief resident medical officer, an advanced trainee in paediatrics, and the lead infectious diseases consultant for AMS. Survey questions were not piloted among JMOs in order to limit pre-exposure to the assessment questions and maximise the number of responses.¹¹ The content included case studies, unidentified errors, and examples of best practice in vital aspects of safe and appropriate medication use in children from admission to discharge. The examples included:

Priority areas were determined after consideration of current practice observed in local audits and the potential risk of harm. Survey questions presented throughout the session were designed to enhance participation, engage JMOs and assess basic concepts before each topic was introduced in the presentation slides.

Informed consent was obtained from JMOs at the beginning of each session. JMOs in attendance were informed that their participation in the survey was voluntary, anonymous and there were no incentives encouraging involvement. Participating JMOs could elect not to respond to individual questions and withdraw at any time. Any data collected through the audience response system prior to their withdrawal could not, however, be excluded due to the anonymous nature of the assessment.

During the session, a presenter read aloud each assessment question and all answer options. The audience response system remained open to receive keypad responses until there was a consensus among the attending JMOs that responses had been submitted. Results were presented in the form of a graphical chart after the close of each survey question. The correct response was confirmed by the presenter; incorrect responses prompted further exploration of the topic and clarification as part of the session. All response options were multiple-choice, ranging from binary responses (yes or no, true or false) to a maximum of 5 response options.

Data collection and extraction

Responses captured during each session were extracted from each of the session presentations with the use of the audience response system software and combined into a single database. Codes were assigned to each session and keypad combination. Attendance records obtained from the Junior Medical Unit determined the sample frame.

Prescribing audits assessed all current medication orders for each patient. ADR documentation, error-prone abbreviations, paediatric prescribing, and orders for intermittent therapy (non-daily administration) were collected in accordance with national quality use of medicines indicator definitions.¹⁶ Two additional NIMC criteria were also collected, the percentage of medication orders with a documented indication, and the percentage of “pro re nata” (PRN or “when necessary”) orders with the maximum number of doses in 24 hours specified.

Statistical Analysis

Descriptive statistics were performed in SPSS 24 (IBM, Armonk, NY). All survey responses and prescription audit criteria were analysed as categorical data and reported as percentages rounded to the closest whole number. Chi-Square tests were used to explore differences in proportion of correct survey responses between JMOs who identified themselves as new employees and those who had previously worked in the institution. Participation was reported for each survey question separately as the proportion of the sample frame with a captured keypad response (i.e. number of responses/number of JMOs in attendance). The extent of participation by individual JMOs throughout each session was reported as the percentage of questions with a response from a single keypad. Kruskal-Wallis tests assessed differences in prescribing each month after the AMS and safe prescribing session. All statistical tests were two-tailed with P values <0.05 considered statistically significant.

Survey

Two hundred JMOs attended orientation, 89 were assigned to an abridged program. Most JMOs had experience in paediatrics; more than half were in the process of completing either Basic or Advanced Paediatric Training. A small proportion of JMOs were Training in other specialties such as general practice, surgical subspecialties, intensive care and emergency medicine (Figure 1).

Figure 1. Medical staff in attendance during safe prescribing and antimicrobial stewardship orientation.¦Basic Physician or Paediatric Trainees have committed to, or are in the process of completing Paediatric Training, with 2 or more years of experience; ^Unaccredited Trainees hold registrar positions but may not have participated in the full College training program; #Advanced Trainees have completed Basic Training; ^^Fellows have completed training; *Training in Other Specialty includes: Intensive Care, Emergency Medicine, Surgical Subspecialties, General Practice and Dermatology 

More than half of all JMOs present responded to at least 80% of the survey questions in their session (Figure 2).

Figure 2. Medical staff participation throughout orientation.Proportion of questions with responses from JMOs in 40 minute session (14 questions) and 1 hour session (17 questions) 

Proportion of questions with responses from JMOs in 40 minute session (14 questions) and 1 hour session (17 questions)

The response rate for individual questions ranged between 31% and 78%. Thirty-nine percent of JMOs (77/200) reported working at the hospital in the previous 12 months and 33% (65/200) indicated they had not.

Information Gathering and clinical decision-making

Almost all JMOs (98%) were aware of NIMC requirement to record the specific reaction, reaction type and the date of occurrence as part of complete documentation. Overall, 85% (132/155) of participating JMOs correctly identified the national paediatric medication reference as the preferred guide for medicines information and dosing at the institution. Among those who reported their prior local experience, the correct option was selected by 96% of JMOs who had worked at the hospital in the previous 12 months and 71% of those who had not (p=0.001) (Table 1).

Communicating and reviewing decisions

Between 70% and 74% of JMOs responded to questions about antimicrobial prescribing. Among those who participated, 95% had heard the term antimicrobial stewardship, and knew that prescriptions for empiric antibiotics should document both the indication and a planned review date in the medical record. Very few respondents considered it appropriate to wait until 72 hours of antibiotic therapy or the next consultant ward round to review empiric antibiotic therapy. The majority indicated reviews should take place at least daily (78%) or every 48 hours (20%). Almost all JMOs recognised that fever alone was not an exclusion for intravenous to oral antimicrobial switch (94%).

Ninety-two percent were aware of the correct method by which to cease an order on the NIMC, specifically, the need to document the date of cessation on the order (124/135). Non-standard terminology (i.e., “6/24” and “1/7) in the order “flucloxacillin PO 500mg 6/24 for 1/7” was identified by 85% of JMOs.

Almost all JMOs recognised that the error-prone abbreviations “IU” and “U” were unacceptable when prescribing medications measured in “international units” and “units” (95%, 141/149). Almost 30% of JMOs were unable to identify the standard terms “mane” and “nocte” from terms that should not be used (OD, D, o.d, M, N, QD, qd). Only 53% could differentiate the standard term “subcut” from the error-prone abbreviations. When asked to count the erroneous and non-standard terms present in the order “clonidine PO .030 mcg 8º x3d then review”, only 60% correctly identified all five (Table 1). Although the response rate was considerably lower than any other question (31%, 62/200), 87% of participants were aware that chemical symbols should not be used when prescribing electrolytes.

Discharge prescriptions

The 60-minute AMS and safe prescribing session included three additional assessment questions to gauge awareness of prescribing requirements for special authority and Schedule 8 medicine (drugs of addiction, e.g. oxycodone, fentanyl, etc.). Approximately 90% of JMOs were reportedly aware that standard hospital prescription forms were unsuitable for supply from a retail pharmacy. Over 90% were aware that multiple Schedule 8 medicines could not be prescribed on a single discharge prescription, and that pre-printed patient identification should not be used for Schedule 8 discharge prescriptions (Table 2).

Prescribing Audit

Nine hundred and seventy-six medication orders were reviewed for 166 patients between 7 February and 6 May 2017. No statistically significant changes in prescribing were observed during the auditing period. Over the three months of auditing, between 63 to 75% of audited patients had an appropriately documented ADR (Table 3). The maximum number of PRN doses was included on 77% of PRN orders, ranging from 84% of orders in period 1 and 70% in period 3 (p=0.08); on average 46% of orders included a documented indication.

Error-prone abbreviations were observed in 5 to 8% of medication orders in the first two months and 2% in period 3 (p=0.09). Almost all intermittent medications were documented according to the national QUM indicator with the non-administration days crossed out (27/28). Dose calculations were consistently documented in approximately half of all orders.