Downloaded from http://ep.bmj.com/ on February 28, 2016 - Published by group.bmj.com
Education & Practice Online First, published on February 26, 2016 as 10.1136/archdischild-2015-309371 E&P: QUALITY IMPROVEMENT
A really wheezy way to save money Felicity J Taylor,1 Grace Li,1 Ofran Almossawi,2 Hasna Dulfeker,3 Victoria Jones1
1
Paediatric Department, North Middlesex University Hospital NHS Trust, London, UK 2 Pharmacy Department, North Middlesex University Hospital NHS Trust, London, UK 3 Paediatric Department, Barnet Hospital, London, UK Correspondence to Dr Felicity J Taylor, North Middlesex University Hospital NHS Trust, Sterling Way, London N18 1QX, UK; felicity.taylor@ doctors.org.uk Received 15 July 2015 Revised 17 December 2015 Accepted 4 February 2016
To cite: Taylor FJ, Li G, Almossawi O, et al. Arch Dis Child Educ Pract Ed Published Online First: [ please include Day Month Year] doi:10.1136/archdischild2015-309371
ABSTRACT Evaluating the cost-saving potential of switching prednisolone formulation in the treatment of childhood wheeze.
PROBLEM Children under 15 years account for 37.8% (20 510 of 54 300) of annual hospital admissions for acute asthma.1 A minimum course of 3 days’ oral steroids is recommended in the British Thoracic Society/Scottish Intercollegiate Guidelines Network BTS/SIGN 2014 guideline on the management of asthma.2 The North Middlesex University Hospital covers a population of 300 000 in the boroughs of Enfield and Haringey in London and dispenses 2400 courses of oral steroids annually for acute asthma and viral-induced wheeze in children. As part of a pharmacy drug spend review, the paediatric and pharmacy teams identified soluble prednisolone as a significant contributor to the drugs budget within the service (over £50 000 annually). A typical 3-day course of soluble prednisolone (at 2 mg/kg as per guidance, or approximately 20 mg) costs £20.88, compared with £2.48 for the equivalent dose of non-soluble prednisolone dispensed with a tablet crusher. Crushed prednisolone can be suspended in liquid but does not dissolve. Several hospital trusts have switched to using non-soluble prednisolone in order to achieve cost savings, but there have been anecdotal reports of poor palatability, raising concerns about compliance with taking medication once discharged. Several clinical commissioning groups are actively encouraging a move away from the prescription of soluble prednisolone in adults, on a cost saving basis.3 We could not find any similar policies or advice regarding children. There is no previously published literature comparing the acceptance of non-
soluble versus soluble prednisolone in children. AIMS The aim of the project was to evaluate whether soluble prednisolone, as prescribed in the management of childhood wheeze, could be substituted with crushed tablets of non-soluble prednisolone without compromising acceptance of the drug, in order to achieve significant cost savings. MAKING A CASE FOR CHANGE The main point communicated to staff was that of the potential cost savings that could be delivered, potentially without compromising care. The paediatric and pharmacy departments disseminated information at staff handovers, by posters and by email. Colleagues were invited to comment or ask questions. There were four main groups of people involved in its implementation: 1. Pharmacy professionals—‘taste test’ participation; ensuring staff were clear about cessation of soluble prednisolone dispensing on the wards; training staff regarding the preparation and dispensing of non-soluble prednisolone; counselling and training of caregivers regarding home dispensing of non-soluble prednisolone; collecting data about tolerability; 2. Nursing professionals—‘taste test’ participation; delivery, explanation and collection of patient and carer reporting forms; dispensing of non-soluble prednisolone; counselling and training of caregivers regarding home dispensing of non-soluble prednisolone; 3. Children, young people and their parents/ caregivers—providing feedback about the tolerability of the drug dose administered; 4. Medical professionals—‘taste test’ participation; correct prescription of soluble and non-soluble prednisolone preparations; case recruitment and distribution of patient and carer reporting forms.
Taylor FJ, et al. Arch Dis Child Educ Pract Ed 2016;0:1–3. doi:10.1136/archdischild-2015-309371
1
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd under licence.
Downloaded from http://ep.bmj.com/ on February 28, 2016 - Published by group.bmj.com
E&P: quality improvement IMPROVEMENTS ACHIEVED Our project used a traditional Plan, Do, Study, Act cycle to guide the implementation of changes (figure 1). We planned to switch the prednisolone formulation from soluble tablets dissolved in water to non-soluble tablets, which would be finely crushed using a tablet crusher. We were aware that the non-soluble prednisolone is extremely bitter, and that the taste needs to be disguised to make it palatable. All staff working on the paediatric ward were asked to take part in a ‘taste test’: crushed non-soluble prednisolone was administered in different flavours of jam and different cordial flavours and concentrations, and staff were asked to choose their favourite. We found that mixing the nonsoluble prednisolone with a small amount of sugarfree jam, or 5 mL of sugar-free blackcurrant cordial helped to make the taste more palatable. It also proved a useful exercise in providing staff insight into the poor palatability of our patients’ medications. One week prior to the project start, posters and information leaflets were made available on the wards. A one-sided A4 reporting form incorporating a modified 5-point hedonic scale was designed (the patient and carer reporting form). All doctors were asked to staple the reporting form to the drug chart of any patient admitted with wheeze that was prescribed prednisolone. Nursing staff helped the child, young person or their caregiver to fill in the reporting form after the dose of medication had been given. They also demonstrated to the parent or caregiver how to crush and administer the non-soluble
Figure 1
2
prednisolone for the take-home doses. Bias may have arisen as it was not always the patient who was responsible for filling in the form; this has to be acknowledged in interpretation of the results. Data was collected from 27 patients over two 3-week study periods. During the first baseline study period, soluble prednisolone was dispensed as normal and evaluated. During the second study period nonsoluble prednisolone was dispensed and evaluated. We found tolerability of prednisolone to be similar before and after formulations were switched: two nontolerated doses of soluble prednisolone (n=17), versus three non-tolerated doses of non-soluble prednisolone (n=10). Both soluble and non-soluble formulations were frequently reported to be ‘Yuk’ by the children and young people. The trust has since made a permanent switch to non-soluble prednisolone for the treatment of all paediatric inpatients with wheeze, and for take-home medications. An information leaflet has been developed for parents or carers to understand how to crush the tablets. We have not had any parent-reported or carer-reported difficulty in preparing or administering the medication. The switch in prednisolone from soluble to nonsoluble formulation represents annual savings of £44 100 for this hospital trust alone (table 1). If universally implemented across all National Health Service (NHS) hospital trusts, substantial savings to the NHS could be achieved, without compromising patients’ clinical care.
Adapted from NHS institute for Innovation and Improvement.
Taylor FJ, et al. Arch Dis Child Educ Pract Ed 2016;0:1–3. doi:10.1136/archdischild-2015-309371
Downloaded from http://ep.bmj.com/ on February 28, 2016 - Published by group.bmj.com
E&P: quality improvement Table 1 Prednisolone Projected Savings—North Middlesex University Hospital Soluble
Non-soluble
Cost of prednisolone for a 3 day course
£20.88
£0.42 (28 tablets)
Cost of tablet crusher
0
£2.06
Total cost per annum (2400 courses)
£50 128
£5952
LEARNING The project was accepted well by all staff, children, young people and their caregivers. Everyone found it interesting and it stimulated debate about which other medications had poor palatability or were suitable for cost reappraisal. Due to the time of year that the project was undertaken, our numbers recruited to the study were relatively small. In future, it would be beneficial to continue to plan these studies jointly with the pharmacy team, as part of an annual review of the suitability and cost and children’s medications.
GP settings. In order to achieve comparable compliance with medication administration, this would require training of staff and community pharmacists about how to administer prednisolone in its crushed form; 3. We encourage further joint working between medical and pharmacy teams to establish whether there are other drugs that might be suitable for a formulation switch; 4. We highly recommend partnership working with children, young people and their caregives from the start of any quality improvement project, and the involvement of staff in the change in policy as well (such as with the ‘taste test’ challenge) in order to maximise engagement with the study. Twitter Follow Grace Li at @gracedocx and Felicity Taylor at @felicityjtaylor Contributors OA, FJT and VJ conceived and planned the study. GL and HD carried out recruitment and data collection. OA provided pharmacy financial data analysis and wrote the caregiver information leaflets. GL performed the final data analysis and drafted the submission jointly with FJT. All authors contributed to the final submission. Competing interests None declared.
Challenges faced
▸ Engagement of MDT—find the right time to communicate with them. The taste test was one of the most useful ways to get the attention of team members ▸ Implementation—having a presence on the ward team is essential ▸ Reinforcing the change—take opportunities to remind your medical and ward team at handovers, on whiteboards, by emails
NEXT STEPS 1. We are now engaging with local general practitioners in Haringey to encourage this switch if not already made; 2. We would advise that all NHS Trust paediatric departments switch prednisolone formulation from soluble to non-soluble, including in Emergency Department and
Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement All raw data can be obtained from the corresponding author.
REFERENCES 1 Asthma Emergency Admissions. Health & Social care information centre. 20th August 2014. hscic.gov.uk/article/ 4989/Asthma-emergency-admissions-fall-in-August-rise-inSeptember (accessed 12 Jul 2015). 2 QRG 141. British guideline on the management of asthma. British Thoracic Society Guideline. 2014. 3 Prednisolone Medicines Information leaflet. UKMi. January 2015. www.midlandsmedicines.nhs.uk/filestore/ QIPPdetailaid-prednisolone-plainvssoluble.pdf (accessed 4 Sep 2015).
Taylor FJ, et al. Arch Dis Child Educ Pract Ed 2016;0:1–3. doi:10.1136/archdischild-2015-309371
3
Downloaded from http://ep.bmj.com/ on February 28, 2016 - Published by group.bmj.com
A really wheezy way to save money Felicity J Taylor, Grace Li, Ofran Almossawi, Hasna Dulfeker and Victoria Jones Arch Dis Child Educ Pract Ed published online February 26, 2016
Updated information and services can be found at: http://ep.bmj.com/content/early/2016/02/26/archdischild-2015-309371
These include:
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Notes
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Education & Practice Online First, published on February 26, 2016 as 10.1136/archdischild-2015-309371 E&P: QUALITY IMPROVEMENT
A really wheezy way to save money Felicity J Taylor,1 Grace Li,1 Ofran Almossawi,2 Hasna Dulfeker,3 Victoria Jones1
1
Paediatric Department, North Middlesex University Hospital NHS Trust, London, UK 2 Pharmacy Department, North Middlesex University Hospital NHS Trust, London, UK 3 Paediatric Department, Barnet Hospital, London, UK Correspondence to Dr Felicity J Taylor, North Middlesex University Hospital NHS Trust, Sterling Way, London N18 1QX, UK; felicity.taylor@ doctors.org.uk Received 15 July 2015 Revised 17 December 2015 Accepted 4 February 2016
To cite: Taylor FJ, Li G, Almossawi O, et al. Arch Dis Child Educ Pract Ed Published Online First: [ please include Day Month Year] doi:10.1136/archdischild2015-309371
ABSTRACT Evaluating the cost-saving potential of switching prednisolone formulation in the treatment of childhood wheeze.
PROBLEM Children under 15 years account for 37.8% (20 510 of 54 300) of annual hospital admissions for acute asthma.1 A minimum course of 3 days’ oral steroids is recommended in the British Thoracic Society/Scottish Intercollegiate Guidelines Network BTS/SIGN 2014 guideline on the management of asthma.2 The North Middlesex University Hospital covers a population of 300 000 in the boroughs of Enfield and Haringey in London and dispenses 2400 courses of oral steroids annually for acute asthma and viral-induced wheeze in children. As part of a pharmacy drug spend review, the paediatric and pharmacy teams identified soluble prednisolone as a significant contributor to the drugs budget within the service (over £50 000 annually). A typical 3-day course of soluble prednisolone (at 2 mg/kg as per guidance, or approximately 20 mg) costs £20.88, compared with £2.48 for the equivalent dose of non-soluble prednisolone dispensed with a tablet crusher. Crushed prednisolone can be suspended in liquid but does not dissolve. Several hospital trusts have switched to using non-soluble prednisolone in order to achieve cost savings, but there have been anecdotal reports of poor palatability, raising concerns about compliance with taking medication once discharged. Several clinical commissioning groups are actively encouraging a move away from the prescription of soluble prednisolone in adults, on a cost saving basis.3 We could not find any similar policies or advice regarding children. There is no previously published literature comparing the acceptance of non-
soluble versus soluble prednisolone in children. AIMS The aim of the project was to evaluate whether soluble prednisolone, as prescribed in the management of childhood wheeze, could be substituted with crushed tablets of non-soluble prednisolone without compromising acceptance of the drug, in order to achieve significant cost savings. MAKING A CASE FOR CHANGE The main point communicated to staff was that of the potential cost savings that could be delivered, potentially without compromising care. The paediatric and pharmacy departments disseminated information at staff handovers, by posters and by email. Colleagues were invited to comment or ask questions. There were four main groups of people involved in its implementation: 1. Pharmacy professionals—‘taste test’ participation; ensuring staff were clear about cessation of soluble prednisolone dispensing on the wards; training staff regarding the preparation and dispensing of non-soluble prednisolone; counselling and training of caregivers regarding home dispensing of non-soluble prednisolone; collecting data about tolerability; 2. Nursing professionals—‘taste test’ participation; delivery, explanation and collection of patient and carer reporting forms; dispensing of non-soluble prednisolone; counselling and training of caregivers regarding home dispensing of non-soluble prednisolone; 3. Children, young people and their parents/ caregivers—providing feedback about the tolerability of the drug dose administered; 4. Medical professionals—‘taste test’ participation; correct prescription of soluble and non-soluble prednisolone preparations; case recruitment and distribution of patient and carer reporting forms.
Taylor FJ, et al. Arch Dis Child Educ Pract Ed 2016;0:1–3. doi:10.1136/archdischild-2015-309371
1
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd under licence.
Downloaded from http://ep.bmj.com/ on February 28, 2016 - Published by group.bmj.com
E&P: quality improvement IMPROVEMENTS ACHIEVED Our project used a traditional Plan, Do, Study, Act cycle to guide the implementation of changes (figure 1). We planned to switch the prednisolone formulation from soluble tablets dissolved in water to non-soluble tablets, which would be finely crushed using a tablet crusher. We were aware that the non-soluble prednisolone is extremely bitter, and that the taste needs to be disguised to make it palatable. All staff working on the paediatric ward were asked to take part in a ‘taste test’: crushed non-soluble prednisolone was administered in different flavours of jam and different cordial flavours and concentrations, and staff were asked to choose their favourite. We found that mixing the nonsoluble prednisolone with a small amount of sugarfree jam, or 5 mL of sugar-free blackcurrant cordial helped to make the taste more palatable. It also proved a useful exercise in providing staff insight into the poor palatability of our patients’ medications. One week prior to the project start, posters and information leaflets were made available on the wards. A one-sided A4 reporting form incorporating a modified 5-point hedonic scale was designed (the patient and carer reporting form). All doctors were asked to staple the reporting form to the drug chart of any patient admitted with wheeze that was prescribed prednisolone. Nursing staff helped the child, young person or their caregiver to fill in the reporting form after the dose of medication had been given. They also demonstrated to the parent or caregiver how to crush and administer the non-soluble
Figure 1
2
prednisolone for the take-home doses. Bias may have arisen as it was not always the patient who was responsible for filling in the form; this has to be acknowledged in interpretation of the results. Data was collected from 27 patients over two 3-week study periods. During the first baseline study period, soluble prednisolone was dispensed as normal and evaluated. During the second study period nonsoluble prednisolone was dispensed and evaluated. We found tolerability of prednisolone to be similar before and after formulations were switched: two nontolerated doses of soluble prednisolone (n=17), versus three non-tolerated doses of non-soluble prednisolone (n=10). Both soluble and non-soluble formulations were frequently reported to be ‘Yuk’ by the children and young people. The trust has since made a permanent switch to non-soluble prednisolone for the treatment of all paediatric inpatients with wheeze, and for take-home medications. An information leaflet has been developed for parents or carers to understand how to crush the tablets. We have not had any parent-reported or carer-reported difficulty in preparing or administering the medication. The switch in prednisolone from soluble to nonsoluble formulation represents annual savings of £44 100 for this hospital trust alone (table 1). If universally implemented across all National Health Service (NHS) hospital trusts, substantial savings to the NHS could be achieved, without compromising patients’ clinical care.
Adapted from NHS institute for Innovation and Improvement.
Taylor FJ, et al. Arch Dis Child Educ Pract Ed 2016;0:1–3. doi:10.1136/archdischild-2015-309371
Downloaded from http://ep.bmj.com/ on February 28, 2016 - Published by group.bmj.com
E&P: quality improvement Table 1 Prednisolone Projected Savings—North Middlesex University Hospital Soluble
Non-soluble
Cost of prednisolone for a 3 day course
£20.88
£0.42 (28 tablets)
Cost of tablet crusher
0
£2.06
Total cost per annum (2400 courses)
£50 128
£5952
LEARNING The project was accepted well by all staff, children, young people and their caregivers. Everyone found it interesting and it stimulated debate about which other medications had poor palatability or were suitable for cost reappraisal. Due to the time of year that the project was undertaken, our numbers recruited to the study were relatively small. In future, it would be beneficial to continue to plan these studies jointly with the pharmacy team, as part of an annual review of the suitability and cost and children’s medications.
GP settings. In order to achieve comparable compliance with medication administration, this would require training of staff and community pharmacists about how to administer prednisolone in its crushed form; 3. We encourage further joint working between medical and pharmacy teams to establish whether there are other drugs that might be suitable for a formulation switch; 4. We highly recommend partnership working with children, young people and their caregives from the start of any quality improvement project, and the involvement of staff in the change in policy as well (such as with the ‘taste test’ challenge) in order to maximise engagement with the study. Twitter Follow Grace Li at @gracedocx and Felicity Taylor at @felicityjtaylor Contributors OA, FJT and VJ conceived and planned the study. GL and HD carried out recruitment and data collection. OA provided pharmacy financial data analysis and wrote the caregiver information leaflets. GL performed the final data analysis and drafted the submission jointly with FJT. All authors contributed to the final submission. Competing interests None declared.
Challenges faced
▸ Engagement of MDT—find the right time to communicate with them. The taste test was one of the most useful ways to get the attention of team members ▸ Implementation—having a presence on the ward team is essential ▸ Reinforcing the change—take opportunities to remind your medical and ward team at handovers, on whiteboards, by emails
NEXT STEPS 1. We are now engaging with local general practitioners in Haringey to encourage this switch if not already made; 2. We would advise that all NHS Trust paediatric departments switch prednisolone formulation from soluble to non-soluble, including in Emergency Department and
Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement All raw data can be obtained from the corresponding author.
REFERENCES 1 Asthma Emergency Admissions. Health & Social care information centre. 20th August 2014. hscic.gov.uk/article/ 4989/Asthma-emergency-admissions-fall-in-August-rise-inSeptember (accessed 12 Jul 2015). 2 QRG 141. British guideline on the management of asthma. British Thoracic Society Guideline. 2014. 3 Prednisolone Medicines Information leaflet. UKMi. January 2015. www.midlandsmedicines.nhs.uk/filestore/ QIPPdetailaid-prednisolone-plainvssoluble.pdf (accessed 4 Sep 2015).
Taylor FJ, et al. Arch Dis Child Educ Pract Ed 2016;0:1–3. doi:10.1136/archdischild-2015-309371
3
Downloaded from http://ep.bmj.com/ on February 28, 2016 - Published by group.bmj.com
A really wheezy way to save money Felicity J Taylor, Grace Li, Ofran Almossawi, Hasna Dulfeker and Victoria Jones Arch Dis Child Educ Pract Ed published online February 26, 2016
Updated information and services can be found at: http://ep.bmj.com/content/early/2016/02/26/archdischild-2015-309371
These include:
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
