WAR QUM …..What is it good for?

A R EVIEW OF Q UALITY U SE OF M EDICINES (QUM) P ROJECTS AT THE M ATER C HILDREN ’ S E MERGENCY D EPARTMENT

O UTLINE Why a Paediatric Emergency Department Hidden agenda General Discussion of QUM project implementation

B ACKGROUND Mater Children’s Emergency Department, 4-week QUM projects are conducted every 6 months 6 different QUM projects completed in the past two years by UQ pharmacy students By reviewing previous projects and investigating the barriers experienced while carrying out these QUM activities, we can improve the quality process of conducting QUM projects in future and ensuring more sustainable interventions

O BJECTIVES To review previous six QUM projects at the Mater Children’s ED To investigate the limitations from various perspectives while these projects were conducted Make recommendations on how to conduct better QUM projects within the Mater Childrens Emergency Department in future To propose potential QUM research topics for future projects

M ETHODS Review previous projects Interview key stakeholders (directed questions)

T HE 6 QUM P ROJECTS 1. Governance of intranasal Fentanyl in Queensland emergency departments 2. Quality Use of Topical Anaesthetic Medicines in the Mater Children’s Emergency Department 3. Implementation and Maintenance of Buffered Lignocaine Programme in a Children’s Emergency Department 4. Dispensing to patients from Mater Children’s Emergency Department after-hours imprest: risk evaluation 5. Nasal Decongestant strategies in children less than 6 months of age 6. Evaluation of the Suitability of Oral Salbutamol in the Management of Paediatric Asthma

1. G OVERNANCE OF INTRANASAL F ENTANYL IN Q UEENSLAND ED Aim of study : To characterise the use and governance structures surrounding the off-label use of intranasal Fentanyl in children. The Nurse Educators of each eligible ED were asked about the use of intranasal Fentanyl – i.e. the indications, dosing guidelines, inclusion and exclusion criteria of use. It was shown that the off-label use of intranasal Fentanyl in children was being used widely and successfully across Queensland's ED however there were variations in dosing guidelines. This study has demonstrated that it is important for a policy to exist for the use of intranasal Fentanyl in children to ensure safe and effective use. Another recommendation : Nurse initiation of intranasal Fentanyl to reduce time to analgesia safely and effectively following appropriate dosing and administration guidelines.

2. Q UALITY U SE OF T OPICAL A NAESTHETIC M EDICINES IN THE M ATER C HILDREN ’ S ED Aim of study : To evaluate the knowledge of medical and nursing staff in Mater Children's ED regarding the use of topical anaesthetics (EMLA 5% vs amethocaine 4%) for children prior to IV insertion. Methods : Printed survey forms asking perceived minimum age limit for the drug usage, dosage, number and sites of application, duration of application, duration of action and effectiveness. Findings: Staffs were generally more familiar with the use of ELMA compared to amethocaine and also signified evidence-knowledge gap in some aspects. Outcomes/Change to Practice Updated evidence-based policy on the use of topical anaesthetic for children presenting in the Mater Children's ED i.e. lower the age limit for the use of topical anaesthetic in children Posters on the use of different topical anaesthetics

3. I MPLEMENTATION AND M AINTENANCE OF B UFFERED L IGNOCAINE P ROGRAMME IN M ATER C HILDREN ’ S ED This project involved:- Literature review on the beneficial use of buffered lignocaine over conventional acidic lignocaine form developing ways to make buffered lignocaine readily available in the ED implementing procedure to encourage the use of buffered lignocaine in the Children's ED. It was signified in literature that using buffered lignocaine can minimise infiltration pain in children. The outcome of the project had led to change in the department's protocol regarding buffered lignocaine. Posters and reminders to ensure that the buffered lignocaine program has sustainable impact.

4. D ISPENSING TO PATIENTS FROM M ATER C HILDREN ’ S ED AFTER - HOURS IMPREST : RISK EVALUATION Aim of study : To review the use of the imprest medication cupboard at the Mater Children's ED and how prescriptions were written to account for the use of these medications. Conducted interviews with ED staffs on how the cupboard was used and how they think improvements could be made. This study had raised awareness on the way the cupboard is being used not only to the ED staffs but also to the Mater pharmacy department who had been largely uninvolved in this process. It also identified financial issues and risks associated with this process and how they could be addressed.

5. N ASAL D ECONGESTANT STRATEGIES IN CHILDREN LESS THAN 6 MONTHS OF AGE This project involved in:- conducting literature review creating a summary table outlining the current nasal decongestant strategies in children < 6 months of age (including benefits, risks and cost) Emphasised the need to further investigate and validate the clinical choices for decongesting nasal passageways in children < 6 months old to ensure more effective treatment.

6. E VALUATION OF THE S UITABILITY OF O RAL S ALBUTAMOL IN THE M ANAGEMENT OF P AEDIATRIC A STHMA A literature review to determine the safety and efficacy of oral salbutamol in the treatment of children's asthma. Findings: Oral salbutamol is less effective and tolerable than inhaled formulation Hence not recommended in treatment of paediatric asthma. The findings was discussed in a letter to the Medical Journal Australia and in a evidence-based medicine website BestBETs hoping to influence prescriber behaviour and reduce the use of oral salbutamol for paediatric asthma.

R ESULTS S O F AR Common Responses Student responses Earlier ethics approval Earlier contact with preceptor Difficult to interact with ED staff Stakeholders Time Sensitivity See projects as worthwhile

F EEDBACK : What do you think would make a good QUM project? Could you give some ideas that would make QUM placements more meaningful for future pharmacy students?