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Standard concentration infusions for paediatric and neonatal care

Development of a national consensus on infusion concentrations for twenty common drugs in paediatric and neonatal care

The problem

The use of weight-based infusions is standard-of-care in the UK.  This method has been shown to be inaccurate with up to 60% variation in actual concentrations in syringes.  The preparation of these syringes is also inefficient with each infusion requiring 40 minutes of nursing time to prepare.  This method of preparation is also a causative factor in infusion prescribing and administration errors, which result in patient harm.  There is a need for safer, more efficient ways of prescribing and administering continuously infused medicines and standardisation is viewed as the main strategy for this.

Aims

This project sought to define a consensus on medication concentrations for the twenty most commonly infused medicines in paediatric and neonatal care. This consensus MUST include morphine and should be delivered by February 2017.This outcome was achieved by:• Taking the range of concentrations defined in a previous scoping survey as the initial concentration framework• Using a modified Delphi technique to arrive at the desired consensus from paediatric professionals• Agree those products that do not arrive at consensus using a conference focus group technique

Making the case for change

Many centres had already identified that weight-based infusions were unsafe and inefficient and the demand for standardisation has been evident since the mid=2000s.  Some centres were starting to use Fixed Concentration Infusions (FCIs), but all were using their own local concentrations which made attempts to procure ready-to-use dosage forms complicated and expensive.  The call to a national consensus was first made through NPPG in 2014 and following this we spoke to stakeholders including RCPCH, the Paediatric Intensive Care Society, NHS England and the Paediatric Chief Pharmacists Group over the course of 2014/15.  This networking culminated in a plenary presentation at the MiST session at the RCPCH Conference in Birmingham in 2015 where the case for a national consensus was made.MiST formally adopted the project as a workstream in January 2016 and the final framework of concentrations was ratified at the MiST conference in February 2017.

Your improvement

An initial scoping survey of concentrations already in use was undertaken in the spring/summer of 2016 and this formed the underpinning framework for the consensus survey.  Survey questions were developed around six clinical scenarios developed with a multi-disciplinary advisory group.  Respondents were asked to choose two concentrations for each scenario.  Consensus was defined as those two concentrations that cumulatively accounted for 70% of the responses.  In the first survey, respondents were also asked to suggest alternative concentrations.  In the second survey, those drugs that did not meet consensus were adjusted with the comments provided and then resurveyed.  Those infusions that didn't achieve consensus at this stage then went intofor conference workshops at the MiST conference in February 2017 and decisions were made collectively.  Response rate to the first and second surveys was 6.5% and 5.3% respectively and respondents were representative of speciality, professional designation and geographical location.  From an initial framework of 37 drugs and 70 concentrations, the final framework contains 18 drugs and 44 concentrations.  No drug has more than three concentrations and only the concentration of clonidine exceeds the maximal concentration recommended for adults (however clonidine is used in different doses between adults and children.)

Learning and next steps

The engagement and comments from participants suggest that the actual concentrations are not the issue, but the wider cultural change that fixed concentration infusions present to routine care.  Therefore, we propose a future wide-ranging human factors based study that will 

  • identify barriers to adoption and implementation and processes to overcome these barriers
  • outline the educational and support tools that should be available to support the safe implementation of FCIs
  • provide risk assessment materials to enable organisations to robustly manage the implementation of FCIs within their organisations.

We also need to explore opportunities for commercialisation of FCIs with appropriate industrial, clinical and NHS organisations.

Quality assurance/MHRA Registration

This project was endorsed by the RCPCH.