Aim To implement the dosing and monitoring recommendations of the national gentamicin guideline for neonates1 and the British National Formulary (BNF) for Children.2 To assist the transition with the development of a decision-making flowchart.
Method A baseline audit (n=30) was conducted in the neonatal unit (NICU) to assess compliance with the national guideline and highlight areas to target for change and improvement. A new local gentamicin guideline and a decision-making flowchart were developed and implemented. Education on the new practices was provided. A post-implementation audit (n=28) was performed to assess compliance and measure changes. The new dosage regimen involved giving a dose of 5 mg/kg every 36 hours to neonates with a postnatal age (PNA) of <7 days, and 5 mg/kg every 24 hours to those with a PNA of ≥7 days. The previous dosing regimen was based on body-weight and postmenstrual age (PMA), and used 24 hourly dosing. Pre-dose (trough) levels were taken before the 2nd dose in both guidelines.
Results Following the development and implementation of the new guideline and flowchart, compliance with the dosing regimen recommended in the national guideline and in the BNF for Children increased by 83% (10% versus 93%, P<0.001). Compliance with local guidance was reduced by 7% (100% versus 93%, p<0.2). Monitoring of renal function (U and Es/creatinine) increased by 35% (46% versus 81%, p<0.01).
Conclusion Decision-making tools can improve dosing and monitoring practices and standardise care.3 Introduction of a flowchart led to increased monitoring of renal function in neonates treated with gentamicin. Medication errors post- implementation were due to medical staff following the old dosing regimen, based on PMA, for premature neonates. There were no administration errors resulting from the change from 24 hourly dosing to 36 hourly dosing. Change can be associated with an increased risk of medication errors as staff adjust to new practices. Continued education is required to support staff through the change process.
Gentamicin Improvement Project Group. Gentamicin: Guidelines for once daily usage in adult and paediatric settings2016. [Available: www.rcpi.ie].
Paediatric Formulary Committee. BNF for children 2016 – 20172016. UK: BMJ Group, Pharmaceutical Press and RCPCH Publications Ltd.
Fonzo-Christe C, Guignard B, Zaugg C, et al. Impact of clinical decision support guidelines on therapeutic drug monitoring of gentamicin in newborns. Ther Drug Monit2014;36(5):656–62.
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