1399 Improving the safety of ciclosporin prescribing in a quaternary immunology and bone marrow transplant unit. (17th August 2022)

• Record Type: Journal Article
• Authors: Dzora, Ella; Rajani, Kalindi; O'Neill, Rebecca; Golwala, Zainab; Kusters, Maaike; O'Sullivan, Catherine
• Is Part Of: Archives of disease in childhood. Volume 107(2022)Supplement 2
• Page Start: A492
• Page End: A493
• Publication Date: 2022-08-17
• Subjects: Children -- Diseases -- Periodicals; Infants -- Diseases -- Periodicals; 618.920005
• DOI: 10.1136/archdischild-2022-rcpch.793
• Languages: English
• ISSNs: 0003-9888

Abstract

Abstract : Aims: Ciclosporin is one of most used immunosuppressants in the Haematopoietic Stem Cell Transplant (HSCT) setting. It is used for, amongst other reasons, Graft versus Host Disease prophylaxis, and Omenn syndrome. Approximately 100 patients per year receive HSCTs in our unit for primary immunodeficiencies, haematological malignancies, and other conditions. Ciclosporin is a drug which requires knowledge of variable dosing, interactions, monitoring, and side effects, including Posterior Reversible Encephalopathy Syndrome (PRES), in order to ensure patient safety. In the year 2021-2022 14 incident reports were logged involving ciclosporin prescriptions. Junior doctors new to the unit routinely describe feeling underconfident in prescribing ciclosporin. We wanted to implement some measures to improve junior doctors' knowledge and confidence in ciclosporin prescribing and therefore patient safety. Methods: We asked 33 junior doctors who had worked on the BMT and Immunology wards over the last year to complete a questionnaire to give their retrospective views on their knowledge of, and confidence in, prescribing ciclosporin at the point when they joined the unit. We also asked them to suggest cost neutral improvements that could be made to support them in the early stages of the job. Additionally, we reviewed the incident reports from the preceding year and audited the prescribing practices from one month of electronic prescriptions, particularly surrounding dose changes, to identify trends and common errors that might not have been highlighted through the incident reporting process. Results: The majority of respondents reported never having prescribed ciclosporin prior to starting the post. Although a few had heard of PRES, the majority stated that they were 'not confident' in prescribing ciclosporin or managing PRES. Although there is a Joint Accreditation Committee ISCT Europe and EBMT (JACIE) guideline on ciclosporin prescribing and management of PRES, respondents felt that, as well as specific teaching on ciclosporin prescribing at induction, a crib sheet with a quick 'how to' guide would be a useful aid. We found that there were some specific areas of prescribing that doctors found more difficult, particularly swapping intravenous to enteral dosing, and making dose changes to maintain levels within the correct range. Conclusion: With input from the junior doctor team, we implemented several changes based on the above results. 1) we created a single page crib sheet that has been stored on the intranet and displayed in the junior doctors' office 2) we wrote a teaching package, in conjunction with the ImmBMT pharmacy team, that would be available on the intranet and would also be delivered at induction 3) we worked with the team behind the electronic prescribing portal to increase the usability and safety netting built in for ciclosporin prescribing. This included making percentage changes in doses trackable and highlighting relevant interactions with increased pop-ups. We hope that the interventions in place will increase junior doctor confidence and patient safety around ciclosporin prescribing. We will follow-up by reviewing the prescribing trends and incident reports in the period following their implementation.