Automated Dose-Rounding Recommendations for Pediatric Medications

Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
PEDIATRICS (Impact Factor: 5.47). 08/2011; 128(2):e422-8. DOI: 10.1542/peds.2011-0760
Source: PubMed


Although pediatric electronic prescribing systems are increasingly being used in pediatric care, many of these systems lack the clinical decision-support infrastructure needed to calculate a safe and effective rounded medication dose. This infrastructure is required to facilitate tailoring of established dosing guidance while maintaining the medication's therapeutic intent.
The goal of this project was to establish best practices for generating an appropriate medication dose and to create an interoperable rounding knowledge base combining best practices and dose-rounding information.
We interviewed 19 pediatric health care and pediatric pharmacy experts and conducted a literature review. After using these data to construct initial rounding tolerances, we used a Delphi process to achieve consensus about the rounding tolerance for each commonly prescribed medication.
Three categories for medication-rounding philosophy emerged from our literature review: (1) medications for which rounding is used judiciously to retain the intended effect; (2) medications that are rounded with attention to potential unintended effects; and (3) medications that are rarely rounded because of the potential for toxicity. We assigned a small subset of medications to a fourth category-inadequate data-for which there was insufficient information to provide rounding recommendations. For all 102 medications, we were able to arrive at a consensus recommendation for rounding a given calculated dose.
Results of this study provide the pediatric information technology community with a primary set of recommended rounding tolerances for commonly prescribed drugs. The interoperable knowledge base developed here can be integrated with existing and developing electronic prescribing systems, potentially improving prescribing safety and reducing cognitive workload.

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Available from: Stephen Andrew Spooner, May 27, 2014
    • "Articles published in English or French between 1998 and 2013 which demonstrated or described safety practices including all types of variants were selected and assessed. In addition, guidelines from medical and pharmaceutical societies and the following reviews about safe practices in the medication use process in pediatrics were consulted11121314151617181920. From this literature review , the research team identified the safety practice domains to build up the tool and they then formulated explicit measurable compliance criteria attached to each domain. "
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    ABSTRACT: Background Although many people are involved in the optimal use of a medication within this process, the use of medications carries risks of adverse events, which are greater in the pediatric population because of many factors. Objective In this context, our aim was to develop a consensus-based list of criteria for the safety of the pediatric medication-use process or circuit (referred to from now on as the CIRCUS tool: CIRcuit-of-Child-drug-USe). Setting Multicenter with a trio of experts from eight university hospitals. Methods A literature search (1998-2013) was conducted in order to identify the different safety practice domains for the pediatric medication use process. Twenty-six safety practice domains were identified and 48 compliance criteria were formulated. In order to reach a consensus on the most relevant compliance criteria for safety practices, an international 24 French-speaking multidisciplinary panelists (8 doctors, 8 pharmacists and 8 nurses) selected to represent a broad range of experience levels and specialties took part in a two round Delphi survey which was conducted between March and July 2013. Each panelist was asked to rate each proposed criterion on a 1-9 Likert scale in order to show their level of agreement (i.e. 1 reflects strong disagreement and 9 reflects strong agreement). Main outcome measure Development of a consensus-base list for safety practices in pediatrics. Results Twenty-two of the 24 professionals invited to take part in this survey (92 % participation rate) completed the two Delphi rounds. At the end of the two Delphi rounds, a total of 38/48 (79 %) safety practice compliance criteria achieved consensus by the panelists. The criteria were grouped into 23 domains. Conclusion This study presents the development of a self-assessment tool for safety practices in the pediatric drug-use process using a Delphi method. This tool may be used in order to record and compare the prevalence of best safety practices in the pediatric drug-use process.
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    • "Finally, we convened a number of expert panels as described in [18]. Using example prescribing cases to create discussion, pediatricians and pharmacists in these panels provided a number of heuristics they use to create a safe and administrable prescription. "
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    ABSTRACT: Pediatric dose rounding is a unique and complex process whose complexity is rarely supported by e-prescribing systems, though amenable to automation and deployment from a central service provider. The goal of this project was to validate an automated dose-rounding algorithm for pediatric dose rounding. We developed a dose-rounding algorithm, STEPSTools, based on expert consensus about the rounding process and knowledge about the therapeutic/toxic window for each medication. We then used a 60% subsample of electronically-generated prescriptions from one academic medical center to further refine the web services. Once all issues were resolved, we used the remaining 40% of the prescriptions as a test sample and assessed the degree of concordance between automatically calculated optimal doses and the doses in the test sample. Cases with discrepant doses were compiled in a survey and assessed by pediatricians from two academic centers. The response rate for the survey was 25%. Seventy-nine test cases were tested for concordance. For 20 cases, STEPSTools was unable to provide a recommended dose. The dose recommendation provided by STEPSTools was identical to that of the test prescription for 31 cases. For 14 out of the 24 discrepant cases included in the survey, respondents significantly preferred STEPSTools recommendations (p <0.05, Binomial Test). Overall, when combined with the data from all test cases, STEPSTools either matched or exceeded the performance of the test cases in 45/59 (76%) of the cases. The majority of other cases were challenged by the need to provide an extremely small dose. We estimated that with the addition of two dose-selection rules, STEPSTools would achieve an overall performance of 82% or higher. Results of this pilot study suggest that automated dose rounding is a feasible mechanism for providing guidance to e-prescribing systems. These results also demonstrate the need for validating decision-support systems to support targeted and iterative improvement in performance.
    Full-text · Article · Jun 2013 · Journal of Biomedical Informatics
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    ABSTRACT: Accurate and informed prescribing is essential to ensure the safe and effective use of medications in pediatric patients. Computerized clinical decision support (CCDS) functionalities have been embedded into computerized physician order entry systems with the aim of ensuring accurate and informed medication prescribing. Owing to a lack of comprehensive analysis of the existing literature, this review was undertaken to analyze the effect of CCDS implementation on medication prescribing and use in pediatrics. A literature search was performed using keywords in PubMed to identify research studies with outcomes related to the implementation of medication-related CCDS functionalities. Various CCDS functionalities have been implemented in pediatric patients leading to different results. Medication dosing calculators have decreased calculation errors. Alert-based CCDS functionalities, such as duplicate therapy and medication allergy checking, may generate excessive alerts. Medication interaction CCDS has been minimally studied in pediatrics. Medication dosing support has decreased adverse drug events, but has also been associated with high override rates. Use of medication order sets have improved guideline adherence. Guideline-based treatment recommendations generated by CCDS functionalities have had variable influence on appropriate medication use, with few studies available demonstrating improved patient outcomes due to CCDS use. Although certain medication-related CCDS functionalities have shown benefit in medication prescribing for pediatric patients, others have resulted in high override rates and inconsistent or unknown impact on patient care. Further studies analyzing the effect of individual CCDS functionalities on safe and effective prescribing and medication use are required.
    Preview · Article · Jul 2012 · Journal of the American Medical Informatics Association
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