415 Quality improvement of methotrexate level monitoring in paediatric oncology patients requiring high-dose methotrexate. (17th August 2022)

• Record Type: Journal Article
• Authors: Widya, Stefani; Dhir, Sunita
• Is Part Of: Archives of disease in childhood. Volume 107(2022)Supplement 2
• Page Start: A439
• Page End: A440
• Publication Date: 2022-08-17
• Subjects: Children -- Diseases -- Periodicals; Infants -- Diseases -- Periodicals; 618.920005
• DOI: 10.1136/archdischild-2022-rcpch.713
• Languages: English
• ISSNs: 0003-9888

Abstract

Abstract : Aims: The Paediatric Oncology Team of Leicester Royal Infirmary acknowledges that Methotrexate levels are coming back late which required it to be handed over to the on-call team to chase and action. The on-call team is most often unfamiliar with the protocols and is busy managing other Paediatric wards. Therefore, there might be a delay to the action that need to be taken from the Methotrexate level (e.g. adjustment of the dose of Leucovorin/Folinic acid). Delay in management could increase the risk of Methotrexate associated toxicity (renal, hepatic, systemic). We aim to ensure all Methotrexate levels are conducted, chased and acted upon within working hours by the day team who are familiar with the protocol to ensure prompt management. Methods: Retrospective data collection of 47 Methotrexate levels taken from Paediatric Oncology patients who required high-dose methotrexate from July - December 2021 from the electronic reporting system and patient notes. Results: Based on a previous audit, there has been suggestions to improve this which consisted of calling the lab prior to sending a sample, calling the lab if the result is not back by 1 hour and trying to start high dose methotrexate infusions earlier in the day. The average (mean) time for the samples to be processed was 1.5 hours. There has been a reduction of samples that took > 4 hours (13% in the previous audit to 6%) ( figure 1 ). Infusions are largely done within working hours; therefore, most samples are sent and can be chased within hours. Out of the 47 samples, 45 (96%) were taken within working hours. However, there was still 5 samples in which the release of the methotrexate level came back outside of working hours. 3 out of these needed to be actioned upon out of hours. Out of the methotrexate levels that needed to be actioned on (18), there were therefore 3/18 (17%) needed to be conducted out of hours by the on-call team ( figure 2 ) whilst the remaining 15 (83%) was done by the ward team during normal working hours. Conclusion: From the previous audit, we are able to conclude that from the interventions implemented, there has been an improvement. Samples are run and reported promptly. There has also been an improvement in ensuring that samples are taken within working hours and infusions started within hours. However, there is still room for improvement as there were still 3 results that came out-of-hours that needed adjustments to the management to be done by the on-call team. Therefore, we have reiterated the importance to try to ensure high-dose methotrexate infusions are started earlier in the day so that levels can be taken in the first half of the day allowing sufficient time for the results to be chased. Furthermore, the lab has suggested to label samples and inform the lab if we expect the levels to be high so that they are able to conduct a neat and diluted sample together, preventing delays due to the need to do a repeat diluted samples on high levels.