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Objectives: To assess dental professionals' perception and knowledge about dental management of patients on antithrombotics and determine if the treatment approach is according to the international guidelines. Methods: This cross-sectional survey was conducted in Saudi Arabia during January 2014-December 2015 and included licensed dentists and hygienists from different dental institutions and Saudi's annual dental conference attendees. Data were collected by using a self-administered questionnaire, with questions about dental management of patients on antithrombotics. Data analysis was done using Statistical Package for Social Sciences statistical software, version 22. Results: Of the 305 participants, 302 completed the survey (dentists: 94.7% and dental hygienists: 5.3%). For traditional antithrombotics, familiarity was higher for Warfarin and Aspirin compared to Clopidogrel. However, for new oral anticoagulants (NOACs), familiarity was significantly less for Rivaroxaban ( P = 0.042). A significant number of participants responded that they were unsure as to how to treat patients [Enoxaparin ( P < 0.001), Rivaroxaban ( P < 0.037), and Dabigatran ( P < 0.027)]. Furthermore, the management of patients on traditional or NOACs was not under guidelines (ranging: 8.2%-42.2%). Conclusion: Dental professionals have limited familiarity with antithrombotics, especially NOACs. Therefore, awareness about NOACs and their impact on dental procedures is needed among dentists in primary healthcare settings, to facilitate proper and timely management.

AimOur paediatric intensive care unit (PICU) has been using the Phillips ICCA electronic prescribing system since 2016. This system has an ‘order set’ function that allows a pre- populated list of medications to be created for use in certain situations. Potential benefits include reduced time to prescribe medications, reduced medication error rate and improved prescribing efficiency. The PICU quality improvement group and Pharmacy Informatics team created an order set for patients under 1 year of age admitted from theatre following cardiac surgery, which was implemented in June 2017. Our theatres do not use the ICCA system so as the patients are transferred with infusions running, there is a time gap where the patient has infusions running on PICU without a live prescription on ICCA. The aim of this project was to establish a reduction in the time taken for all 13 medications to be prescribed. In turn this would reduce the risk of running infusions without a live prescription.MethodsData was collected retrospectively from the ICCA system on 15 patients pre and 15 patients post the introduction of the order set. Time of admission was set when the patient was allocated a bed on ICCA. The times at which each medication was prescribed were taken directly from ICCA. A user satisfaction survey was also sent out to during the order set implementation phase.ResultsThe time taken to prescribe all 13 medications was reduced on average by 9.4 hours per patient. The average time saved per medication was 43 minutes. Pre implementation, the average time to prescribe the medications was 11.4 hours (95% CI [5.5, 17.3]). Post implementation, the time taken to prescribe the same medications was 2 hours (95% CI [0.5, 3.5]). Pre implementation, prescriptions were started at least 30 minutes (average) after the patient arrived on PICU. Post implementation, prescriptions were started 30 minutes before patient admission and completed within 30 minutes of arrival. 20 staff members completed the user satisfaction survey. The survey had a 13% return rate. 70% of users agreed or strongly agreed that using the order set function improved prescribing efficiency and 55% of users agreed or strongly agreed that the order set helped ensure appropriate doses.ConclusionImplementation of an order set for this patient group removed the risk of running infusions without a live prescription. This project is an example of how prescribing support functions within electronic prescribing packages can reduce time taken to write up medications within our unit, allowing prescribers to spend more time on other duties. Following the success of this intervention, further order sets will be created for use on our unit. A high level of clinical knowledge from the pharmacy support team and strong engagement with the clinical team was essential in creating a product that was fit for purpose. Limitations of this project are that we did not have the capability to assess a reduction in medication error. We now have increased support within the Pharmacy Informatics team...

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Background: Risk of bleeding post dental extractions in patients on the anticoagulant medication is not well-established. The aim of the study is to investigate the incidence of postoperative bleeding following dental extractions in adult patients on antithrombotic medication in Saudi Arabia. Methods: A retrospective study of 539 patients aged 18 to 93 years of age, attended 840 visits for dental extractions from January 2012 to June 2016 at a tertiary care hospital in Saudi Arabia. All returning patients were treated as outpatients with local hemostatic measures. Results: Only 1.7% of the visits were associated with post-operative bleeding following dental extractions. The highest risk of bleeding occurred in patients on Warfarin (3.88%), while those on Clopidogrel had no risk associated with bleeding. Women were found to have the highest rate of bleeding associated with dental extractions especially those on new oral anticoagulant medications. Conclusion: Dental extractions can be safely performed on adults receiving antithrombotic treatment provided established guidelines are followed. Health care professionals must exercise caution when planning invasive dental treatment for patients on continued antithrombotic therapy. Disclosures No relevant conflicts of interest to declare.

AimA guideline for the use of intermittent intravenous vancomycin in children was designed and implemented in our Trust in 2016. This introduced the use of a loading dose, increased dosing and increased frequency compared to the BNFC recommendations. The changes were based on the outcomes of a national NPPG project and local focus groups. The aim of this audit was assess compliance with the guideline and to establish if the time taken to reach target vancomycin levels had been reduced as a result of using the new guidance.Methods30 paediatric patients (≥1 month old) prescribed intermittent intravenous infusions of vancomycin were identified by ward pharmacists over a 2 month data collection period. 4 patients required treatment with adult dosing due to their weight. 2 patients were switched onto continuous infusion following pharmacist intervention. The results of the remaining 24 patients were compiled into an excel spreadsheet for analysis.ResultsAudit pre-implementation of the guideline had highlighted the lack of a support for staff to use appropriate dosing and monitoring.1 Overall, usage of the new guideline was positive. The loading dose was used appropriately in 83% patients. Levels were taken at appropriate times in 90% patients. The percentage of levels in therapeutic range at 48 hours increased from 7% to 40%. 100% of patient had a review at this time. Half of the patients out of range at 48 hours had treatment stopped or changed to a more appropriate treatment, reducing the need for unnecessary complex dose adjustment/monitoring plans. At 48 hours, there remained 30% of the total patient group requiring dose adjustment in order continue vancomycin treatment. The main area of concern was that review of these out of range levels was only carried out in accordance with the guideline in 40% of cases. This was improved to 80% with pharmacist intervention. A limitation of this data was the small patient group size. One patient had the level taken at the wrong time so could not be interpreted properly.ConclusionCompliance with the new guideline was good overall. This audit has shown that the use of the new guideline improved the percentage of patients with vancomycin levels in range at 48 hours from 7 to 40%. The main theme from this audit was that pharmacist intervention was the key to directing the medical teams towards prescribing the most appropriate form of treatment. Education can only improve compliance to a certain degree and this drug is not used often enough to be familiar to the average junior doctor. The use of vancomycin in complex and requires an understanding of pharmacokinetics and drug handling unique to the pharmacist skill set. Our aim for the future is that as our pharmacist team acquires more independent prescribers, direct adjustment of treatment plans will become a pharmacist role within the Trust.ReferenceHaylor J. Vancomycin use in paediatrics - prescribing and monitoring. University Hospitals Bristol Foundation Trust Clinical Audit 2014.

Aims the Neonatal and Paediatric Pharmacists Group (NPPG) supported two paediatric pharmacists to work with the online Medusa injectable medicines guide to improve the paediatric content of the website, initially for a 12 month period. The aim of this survey was firstly to understand what resources hospital pharmacists currently use to advise their nursing and medical staff on the administration of injectable medicines for paediatrics. The second aim was to assess current opinions regarding the Medusa website from our paediatric pharmacist colleagues in terms of challenges in using the website and potential solutions to overcoming those challenges. Method An online survey was designed using Survey Monkey and sent to all NPPG pharmacists using the NHS networks message board, as well as all registered users of Medusa. 145 responses (after combining multiple responses from the same centre) were analysed from UK NHS and Irish hospitals. Results Our results showed that almost all centres treat patients under 18 years of age (92%) and 83% of centres had access to Medusa either just for their pharmacists or at ward level. 25% of centres used hard copies of in-house designed IV guides at ward level, hence some centres used both Medusa and in-house guides. The in-house guides were in some cases written by pharmacists at that Trust, in other cases adapted from IV guides written by pharmacists at neighbouring Trusts. District general hospitals were more likely to use Medusa as the sole resource whereas specialist children's hospitals were more likely to their in-house guide as the sole resource. Other resources used were the BNF for children and Guys and St Thomas' Hospital formulary. Further resources were only used by centres with designated paediatric medicines information pharmacists. The IV guidance used for children often varied dependEnt on their age. For example, Trusts only treating adolescents and adults would mostly not have separate guidelines for the children. Often also, Trusts used different guidance for neonates on an intensive care unit, compared to neonates on a general ward. 57% respondents provided dosing information as well as administration information to their wards. Medusa does not provide dosing information and this can often be seen as a barrier to its use. Some centres provided dosing information via their in-house guides, but other centres adapted the Medusa monographs by using a function called “local guides” within the website to add information specific to that centre or area within the centre e.g. paediatrics, or intensive care. Respondents recognised that although they produced their own guides, this was becoming an increasingly unsustainable workload and that Medusa was increasingly being used as the main alternative resource. Conclusions The responses were used to create action plans for the NPPG pharmacists working with Medusa: ▸ Review each Medusa monograph for paediatric content ▸ Edit wording to reduce monograph length wherever possible ▸ Include practical information, rather th...

Aim To present the findings of the Decreased Conscious Level Multi-site Audit which examined selected recommendations from the RCPCH-endorsed guideline: The Management of a Child with a Decreased Conscious Level. Methods 51 NHS trusts collected data on consecutive cases of children less than 18 years who presented acutely with a decreased conscious level between the period: 1 November 2010 to 30 September 2011. These trusts used either a wholly retrospective or a combined prospective/retrospective approach to identify the cases. Data was collected on 1147 cases, of which 1132 met the audit's inclusion/exclusion criteria. Results Trusts performed well for the documentation of heart rate (50/51, 98.0%) and to a lesser degree for respiratory rate (37/51, 72.5%), oxygen saturation (46/51, 90.2%) and the use of either Glasgow Coma Scale or AVPU scale to assess the level of consciousness (46/51, 90.2%). However, the documentation of blood pressure (11/51, 21.6%) and temperature (31/51, 60.8%) was of a poorer standard. In the majority of trusts, there was a failure to meet the audit standards for the recommended clinical history features which should be elicited from these children and young people. Very few trusts met the performance targets for the documentation of the presence or absence of the following clinical history features: vomiting (4/51, 7.8%), fever (4/51, 7.8%), convulsions (4/51, 7.8%), alternating periods of consciousness (11/51, 21.6%), trauma (2/51, 3.9%), ingestion of medication or recreational drugs (2/51, 3.9%) and length of symptoms (23/51, 45.1%). Measurement of capillary glucose only met the standard in 18/48 (37.5%) trusts. Although, no performance targets were set for these areas, the majority of the trusts failed to achieve even a minimum level of 75% or more. There were low levels of documentation on whether parents were allowed to stay with their child (9/51, 17.6%), informed regarding their child's possible diagnosis (13/51, 25.5%) and possible prognosis (8/51, 15.7%). Conclusions There were significant gaps in the documentation of observations, clinical history, investigations and communication with parents in the care of children and young people presenting acutely with a recognised decreased conscious level. A revised guideline will aim to address these issues.