This was a quality improvement project to train multidisciplinary healthcare teams to teach children and young people on long term medication how to take tablet medication in an out-patient setting.
We were based in a children’s hospital. Our team was truly multi-professional, made up of pharmacists, nurses, doctors, psychologists and play specialists,
Tablet medications are safer, more convenient and considerably cheaper than liquid. Our family and staff feedback highlighted families frustrations with liquid medicines. They often have short expiry dates, need refrigeration, are difficult to obtain from local pharmacies, can cause dental decay and many are unpalatable. In addition many are unlicensed and costly (e.g. Nitrofurantoin cost £9 tablets vs. £447 liquid per month). Liquids can vary in concentration, making accurate dosing more difficult and introducing a safety concern. Dose errors are common, particularly in families with low health literacy and limited English proficiency.
In 1980s HIV medication was only available in tablets so paediatric infectious disease (PID) clinicians had no choice but to teach children from 4 years to swallow tablets. Yet nurses and parents of children with chronic kidney disease, when we surveyed them, suggested that patients should be at least 10 years old before attempting tablet conversion. The renal team paired up with PID team to share knowledge and set up a system to convert children to tablets.
Working with families and our teams we created an interactive training package with video and comic poster. We ran interactive hour-long training sessions for staff. Using positive reinforcement and play, the trainer sat facing the CYP with sweets or dummy filled capsules of increasing sizes. The tablets were placed in the centre of the tongue, with the head in a neutral position and the CYP swallowed by drinking or sucking from a sports bottle or straw.
>5 years attending complex renal clinics to be converted from liquid to tablet medication unless contraindicated (e.g. swallowing or cognitive impairment). Outcome measures included successful conversion rate, patient and staff feedback and cost savings. Savings were compiled from our pharmacy computer system comparing cost of each CYP remaining on liquid medication compared with tablets for one year.
We overcame practical barriers by placing easily accessible ‘switching kits’ in clinic filled with the necessary sweets, pre-packaged dummy pills, awards and certificates. To increase confidence, we created a sealed dosette box with common medications so children could see the size of tablets they needed to swallow. Working with pharmacists, prescribers and clinic nurse we standardised processes (e.g. how to round doses to the nearest tablet or half tablet, pre-screening clinic lists to select eligible children and writing prompts in clinic letters) and collected data.
Over three months, 90 CYP were seen in 13 multi-disciplinary renal clinics, 25 CYP on liquid medication without contraindications were suitable for conversion to tablet medication. 21 CYP (median age 8.4 years range 5.1 to 15.5) were successfully converted (only one patient required two sessions). Two adolescents were able to swallow small tablets but have not yet reached the required tablet size, and the remaining 2 have yet to be trained. 36 medicines were switched, generating £46,588 per year recurrent savings.
Feedback was good. Staff liked the opportunity for positive interaction with children and families appreciated the ease of obtaining tablet medications versus liquids. We subsequently trained other teams, including our research team who were recruiting for a study in which swallowing tablets is an inclusion criteria. The study team had our resources translated into different languages.
From the success of one small team we have trained other teams and have truly spread this project locally, regionally and nationally. In our hospital over 100 multi-disciplinary staff have undergone training. This is not a new idea and we know of individual clinicians who have been teaching their patients how to swallow tablets for many years. However we know of no other children’s hospital where many multi-disciplinary teams are being taught this skill to be implement widely.
This project has been presented orally at numerous regional meetings (e.g. winner of Bright Awards in Healthcare 2019, winner of Yogi Ql prize for innovation, Great North Pharmacy Conference, North of England Paediatric Society meeting, AHSN Q event) and national meetings (British Association for Paediatric Nephrology Annual Conference 2019, British Paediatric Nephrology Nurses conference 2019 and have a plenary presentation at the upcoming RCPCH annual conference 2020).
Educationally it has been delivered to Paediatric Specialty Trainee training Day and at North East Paediatric Pharmacist Training Day and we are co-producing e-learning packages to embed into medical and nursing student curriculum in our North East universities. Other paediatric units have approached us and we are offering practical help with team training. The project has been published in Archives of Disease and Child Health, the medical journal for all UK paediatrians as well as the Academic Health Science Network Atlas of Solutions in Healthcare.
We are already spreading to other units across the region. We feel there is massive scope for spreading to GPs, community and school nurses and health visitors. Through our training sessions we discovered many adults have never learnt to swallow tablets and having ready access to health professionals who can teach them in ten minutes can be transformative to their health.
In a short timeframe we have demonstrated it is possible to embed a system to convert children to tablet medication, improve the families’ experience of obtaining medication and realise considerable cost savings. It requires staff training and cultural change. Pill swallowing is an easy skill to teach and learn, and children as young as five can successfully swallow pills. Parents were more likely to change if we discussed potentials benefits first.
We automatically teach inhaler technique so equally we should teach CYP how to swallow tablets as a life skill. We would encourage all units to set up pill swallowing training, and for all medical and nursing schools to equip their graduates with this key paediatric skill as it is simple, rewarding and cost saving.
Conversations with families was key to this project. This quality improvement project was only successful because of multidisciplinary team work focusing on the benefits to the family and child / young person. From the start, the idea came from our team speaking to families who came to clinic and learnt what the barriers were, or who phoned up in desperate need as they have ran out of medication or dropped a bottle of liquid medication in the middle of a weekend and had nowhere to obtain new supplies. Our Ql project relied on the children telling us what worked and did not work during training.
The perils of liquid medication is well known, the author has just completed a study looking at 10x medication errors in children in Wales over the last two years which found nearly all the oral medication errors were from liquid medications and is working with NRSL and RCPCH medicines committee to minimise this.