Advanced practice in paediatric pharmacy: What is it, how do you get there, and what does it mean for children?

Abstract

The quality and safety of medicines use is as important in paediatrics as in adult medicine, and closely linked to the skills, knowledge, attitudes and behaviours of health professionals responsible for patient care. The aim of this research was to investigate advanced paediatric pharmacy practice; how to develop and assess advanced skills; and how these skills improve outcomes for children.Prevention of adverse medication events (AMEs) is the most researched pharmacy impact on patient outcomes. However, there is limited evidence in paediatrics. The first phase of this research investigated AMEs in children, with the hypothesis that: Voluntary reports of AMEs can be used to identify trends over time in response to safety improvement initiatives, and identify associated skills required of health practitioners.The first component of this phase reviewed six months of potential and actual AMEs identified from three databases: clinical incident reports, pharmacist intervention reports and administrative coding using the International Classification of Diseases 10th Revision (ICD-10). Analysis identified 447 individual AMEs. Little duplication between data sources was found. ICD-10 coding identified the most cases of harm, and intervention and incident reports identified the most cases of error. ICD-10 events rarely involved error and were time-consuming to retrieve, hence this method was not used in subsequent research.The next component reviewed eight years of voluntary reports of medication related events (MREs). 10,865 MREs were investigated. Two categories were reviewed in detail: chemotherapy prescribing and potassium errors. Potassium errors reduced from 6.3 to 2.2 per 10,000 occupied bed days from 2008 to 2012. Chemotherapy prescribing errors decreased from 4.2 to 1.1 per 100 oncology separations from 2005 to 2012, particularly errors in chemotherapy protocols. Education alone did not produce sustained change. System changes including forcing functions, executive endorsement and strong multidisciplinary engagement resulted in most improvement. Health practitioners required advanced skills in education, change and risk management, communication, teamwork, leadership, and research methodology.The second phase of research tested the hypothesis that: Paediatric hospital pharmacists value formal recognition of advanced pharmacy practice, can describe the characteristics of advanced practitioners and identify preferred methods of assessment of advanced practice.Four focus groups, involving 31 Australian paediatric pharmacists, concluded that advanced practice should be formally recognised, and include a foundation in clinical practice, together with education, research and service improvement outside the institution. Multiple methods of assessment were recommended; most preferred were direct observation of practice, peer review and portfolio review. Knowledge of paediatric diseases and drug handling, and skills in communication with children and families, were important.The third phase of the project reviewed two existing datasets to test two hypotheses, the first of which was: Pharmacist interventions can document progression to advanced practice.Six hundred interventions recorded by four pharmacists from one paediatric hospital were retrospectively reviewed over three separate periods from 2005 to 2012. Skills demonstrated in these interventions were rated using a pilot scale from 1 to 5, representing skills typical of intern pharmacists through to advanced practice. Skills increased over time, with more Level 3-5 interventions recorded in the later time periods, and mean skill level increasing from 1.9 to 2.6 (p<0.01).The second hypothesis in this phase was: Training and development priorities in paediatric pharmacy can be identified by direct observation of pharmacists working in clinical practice.This study retrospectively reviewed six years of paediatric pharmacist competency assessments using the General Level Framework (GLF). Fifty assessments were retrieved from ten Queensland hospitals, including specialist and general hospitals. Ethics, confidentiality, legal compliance and appropriate dosages were performed consistently well. However, assessment of patients’ understanding of illness and treatment, and assessment of adherence, were not performed well. This study demonstrated that the GLF could be used to evaluate competency and identify training needs in the paediatric setting.The final phase of the research tested the hypothesis that: Advanced level paediatric pharmacy practice is most reliably evaluated using multiple assessment methodsThirty-six pharmacists were recruited from four Australian paediatric hospitals. Six assessment methods (direct observation of practice, peer review, portfolio review, viva voce, knowledge assessments and self-assessment) were tested over 12 months. Each method was scored against the Paediatric Advanced Level Framework. Qualitative and quantitative analysis of scores, ranking, and participant and evaluator feedback found the most reliable methods were portfolio review, peer review and oral viva. Postgraduate qualifications, CPD records, and direct observation of practice using the GLF or shpaclinCAT, provided less reliable scores and were not preferred by participants or evaluators.This research project demonstrates the value of advanced practice to Australian paediatric pharmacists as a career pathway; the importance of advanced skills to safe medication use in paediatrics; and the importance of using a combination of assessment methods to evaluate advanced practice. Future work includes development of an electronic portfolio, a paediatric curriculum linked to accessible training, and formal credentialing of advanced pharmacy practitioners.