Avoiding adverse drug reactions in children - development of the Liverpool Adverse Drug Reaction Avoidability Assessment Tool

Adverse drug reactions (ADRs) are common in children. They contribute significantly to patient morbidity, mortality and hospitalisation costs. There is limited data on the avoidability of ADRs in children and wide variation in avoidability rates has been reported. There is currently no standardised method for determining avoidability and many of the established tools are not suitable or designed for use in paediatrics. The aim of this thesis was to develop and test a new avoidability assessment tool that is suitable for use in paediatrics. The stimulus for this work was difficulty using other tools including the one developed by Hallas et al. (1990). Ideally the new tool should also be applicable and generalisable to a variety of other settings. A secondary objective was to identify potential strategies for clinical practice that might reduce the incidence of ADRs. Three key themes for avoidability have been established through a review of existing literature these are: inappropriate or suboptimal prescribing, inadequate monitoring and inadequate patient or parent education. The development of the LAAT was a multistep process which involved a multidisciplinary team (MDT). Individual and group assessments were conducted and qualitative and quantitative analyses of the assessments were carried out. The LAAT has undergone validity and reliability testing for groups and individuals. The newly validated LAAT was used to assess 249 ADR case reports from a prospective paediatric admissions study by one individual and compared to existing avoidability assessments conducted using the Hallas scale. Assessment of these ADR case reports using the LAAT found that 19.3% were either possibly or definitely avoidable. This was similar to results using the Hallas scale where 22% of the reactions were either possibly or definitely avoidable. Overall percentage exact agreement (%EA) between LAAT and the Hallas scale was 90%; when subcategorised into oncology and non-oncology cases the %EA was found to be 94.2 and 86% respectively. The kappa score between LAAT and Hallas scale assessments was 0.71 (95% CI 0.60 - 0.82) for all cases, 0.54 (95% CI 0.40 - 0.68) for the oncology cases and 0.73 (95% CI 0.58 - 0.88) for the non-oncology cases. The most common avoidability theme detected in this study was inappropriate or suboptimal prescribing. Assessing the avoidability of ADRs is a complex process which requires taking into account a number of factors. Strategies to avoid ADRs can be applied at different levels including: patient, ward, departmental institutional, professional, and national. A common theme that emerged from this work was the lack of available guidelines that could be used to assess whether ADRs were avoidable. Where guidelines were available few contained information about ADRs or their prevention. The majority of clinicians relied on their experience and tacit knowledge rather than on guidelines. Some of the ADRs categorised as either possibly or definitely avoidable may have been avoidable with improved prescribing, more frequent monitoring or improved education of patients and/or parents. Other possible prevention strategies include creating an awareness of ADRs in general and their prevention throughout a clinician’s training. Improved communication and documentation in patient records is a simple but effective method of ADR reduction. In summary, we have designed a novel avoidability assessment tool, developed by a multidisciplinary team, and have shown that the new tool is comparable to an existing avoidability tool, can be used by individuals and most importantly is suitable for use in paediatrics or other areas where clinical conditions extend beyond the expertise of individuals. The LAAT refers to guidelines and patient history rather than to abstract concepts such as ‘present-day knowledge of good medical practice’ and ‘effort exceeding the obligatory demands’ as per Hallas. Further work to identify potentially avoidable ADRs and strategies to prevent them is needed

Inclusive recovery planning for incremental systemic change: A methodology, early outcomes, and limitations from the Falkland Islands' Covid‐19 recovery planning experience

Crises do not affect populations equally but expose and exacerbate long-standing vulnerabilities and inequalities. Recovery language such as ‘build back better’, or ‘bounce forward’ has been criticised for neglecting underlying inequalities. This paper reports on the process and early outcomes of an inclusive Community Recovery Planning process for the Falkland Islands, in response to Covid-19. The Falkland Islands is home to a complex community, with close ties and short power distances (due to its small size and remoteness), with differences institutionalised in citizenship statuses and entitlements, and shaped by geopolitical tensions. We aimed to use the ‘pandemic as a portal’, seeking out previously ‘less heard’ voices, to make visible previously hidden impacts, and initiate incremental systemic change to tackle them. Community Impact Assessments evidenced specific areas of vulnerability (e.g., housing and income insecurity) and inequalities, largely shaped by differing citizenship status. In tandem with other government currents, the Community Recovery Planning process has contributed to progressive policy changes in Equalities legislation and Income Support. We offer this paper as a demonstration of our methodology for inclusive recovery planning that could be adapted elsewhere. We argue that the inclusion of previously unheard voices contributed to incremental systemic change to reduce inequalities

'A hard-won capability': the experiences of parents managing their babies' medicines after discharge from a neonatal unit.:'A hard-won capability'

IntroductionParents of babies who required neonatal care are responsible for managing their medicines after they are discharged home. There is wide variation in the information and amount of preparation given to parents prior to assuming this challenging task. The aim of the Parent co-Designed Drug Information for parents and Guardians Taking Neonates home (PADDINGToN) study was to explore parents' experiences of managing their babies' medicines post discharge from a neonatal unit and to use this information to develop suitable resources for future families.MethodsA qualitative participatory interpretative approach using a mixture of remote and face-to-face small group interviews or one-to-one interviews was used. Parents were recruited using social media advertisements and convenience sampling from five study sites (four neonatal units in England and one in Ireland). Parents from other neonatal units were invited to take part through social media advertisement. The interviews were audio-recorded and inductive reflexive thematic analysis was used to analyze the data.Results17 parents (14 mothers, 3 fathers) participated. One over-arching theme, 'A hard won capability', and four major interpretive themes were generated from the analysis of the data: Being in NICU and the prospect of going home: emotional and practical challenges; Living the reality of being at home: the uncertainty associated with giving medicines; Being at home: battling the system and a lack of support/knowledge; and Suggesting ways forward: parents' lived insights into improving information and resources.ConclusionDespite the challenges they faced, parents developed strategies for safely and reliably managing medicines administration and they assimilated knowledge, built their confidence and achieved a capability in medicines administration. Their experiences have been used to build a suite of medicines administration resources to support future parents.</jats:sec

Critical assessment and validation of a time-integrating fluvial suspended sediment sampler

Delivery of fine sediment to fluvial systems is of considerable concern given the physical and ecological impacts of elevated levels in drainage networks. Although it is possible to measure the transfer of fine sediment at high frequency by using a range of surrogate and automated technologies, the demands for assessing sediment flux and sediment properties at multiple spatially distributed locations across catchments can often not be met using established sampling techniques. The time-integrated mass-flux sampler (TIMS) has the potential to bridge this gap and further our understanding of fine sediment delivery in fluvial systems. However, these devices have undergone limited testing in the field. The aim of this paper was to provide a critical validation of TIMS as a technique for assessing fluvial fine sediment transfer. Fine sediment flux and sediment properties were assessed over 2 years with individual sampling periods of approximately 30 days. Underestimation of sediment flux ranged between 66% and 99% demonstrating that TIMS is unsuitable for assessing absolute sediment loads. However, assessment of relative efficiency showed that six of seven samplers produced statistically strong relationships with the reference sediment load (P < 0.05). Aggregated data from all sites produced a highly significant relationship between reference and TIMS loads (R2 = 0.80; P < 0.001) demonstrating TIMS may be suitable for characterizing patterns of suspended sediment transfer. Testing also illustrated a consistency in sediment properties between multiple samplers in the same channel cross section. TIMS offers a useful means of assessing spatial and temporal patterns of fine sediment transfer across catchments where expensive monitoring frameworks cannot be commissioned

Paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT): an e-survey of the experiences of parents and clinicians.

BackgroundLittle evidence exists about parental satisfaction and their influence on referral to paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT).AimThis study aimed to examine the experiences of parents, children and clinicians of OPAT at a large tertiary children's hospital.MethodA prospective e-survey, using closed and open questions, of parents (n = 33) of 33 children who had received OPAT (3 children completed a survey), and clinicians (n = 31) involved in OPAT at a tertiary hospital. Data were collected September 2016 to July 2018.ResultsData were analysed using simple descriptive statistics. The results show that OPAT offered benefits (less stress, re-establishment of family life) compared to hospital-based treatment for parents and children, although some were anxious. Clinicians' referral judgements were based on child, home, and clinical factors. Some clinicians found the process of referral complex.ConclusionMost parents and children were satisfied with the OPAT service and preferred the option of home-based treatment as it promoted the child's comfort and recovery and supported family routines

Bank erosion events and processes in the Upper Severn basin

This paper examines river bank retreat rates, individual erosion events, and the processes that drive them in the Upper Severn basin, mid-Wales, UK. Traditional erosion pin networks were used to deliver information on patterns of downstream change in erosion rates. In addition, the novel automatic Photo-Electronic Erosion Pin (PEEP) monitoring system was deployed to generate near-continuous data on the temporal distribution of bank erosion and accretion: this allowed focus on the magnitude and timing of individual erosional and depositional events in relation to specific flow episodes. Erosion dynamics data from throughout the Upper Severn basin are combined with detailed information on bank material properties and spatial change in channel hydraulics derived from direct field survey, to assess the relationships between flow properties and bank erosion rates. Results show that bank erosion rates generally increase downstream, but relate more strongly to discharge than to reach-mean shear stress, which peaks near the basin head. Downstream changes in erosion mechanisms and boundary materials, across the upland/lowland transition (especially the degree of development of composite bank material profiles), are especially significant. Examples of sequences of bank erosion events show how the PEEP system can (a) quantify the impact of individual, rather than aggregated, forcing events, (b) reveal the full complexity of bank response to given driving agents, including delayed erosion events, and (c) establish hypotheses of process-control in bank erosion systems. These findings have important implications for the way in which bank erosion problems are researched and managed. The complex responses demonstrated have special significance for the way in which bank processes and channel-margin sediment injections should be handled in river dynamics models