Background There are large groups of children where families have problems obtaining ongoing supplies of their children’s medicines in primary care due to them being high risk and complex, unlicensed, off label or expensive. The KidzMeds project was established ‘For all children to get the right medicine at the right dose at the right time with the right monitoring with minimum fuss wherever they live.’
Tablets are safer, more convenient and cheaper than liquid medications. Children often remain on liquid due to habit, reluctance and parental and staff not knowing how to convert. The idea of converting came from initial HIV medications which were only available in tablets1; children as young as 3 years could be taught.2 3
Aim Quality improvement project to teach children and young people (CYP) on long term medication how to take tablet medication in an out-patient setting.
Method Working with families and our teams we created an interactive training package with video (http://northernpaediatrics.com/kidzmed/) and comic poster. We ran interactive hour-long training sessions for staff. Using positive reinforcement and play, the trainer sat facing the learner with sweets or dummy filled capsules of increasing sizes, from size 3 (15 mm) to size 00 (23 mm).
Over the next 12 weeks in one team we embedded a process for children ≥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.
We overcame practical barriers by placing easily accessible ‘switching kits’ in clinic filled with the necessary 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 the clinical team we standardised processes (e.g. how to round doses, pre-screening clinic lists and creating prompts).
Results Over three months, 90 CYP were seen in 13 multi-disciplinary renal clinics, 25 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). 36 medicines were switched, generating £46,500 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.
Conclusions In a short timeframe it is possible to embed a system to convert children to tablet medication, improving patient experience and realising 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. We automatically teach inhaler technique so equally we should teach CYP how to swallow tablets as a skill for life. We would encourage all units to set up pill swallowing training.
Fischl MA, et al. The efficacy of azidothymidine (AZT) in the treatment of patients with AIDS and AIDS-related complex. NEJM 1987;317:185–91
Garvie PA. Efficacy of a pill-swallowing training intervention to improve antiretroviral medication adherence in pediatric patients With HIV/AIDS. Pediatrics 2007;119:e893–e899
Patel A, et al. Effectiveness of pediatric pill swallowing interventions: a systematic review. Pediatrics 2015;135:883–889
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