“Introducing pill school requires minimum consumable cost for sweets and capsules. Different models exist but requires a small multi-disciplinary team of enthusiasts to learn to teach children, then in a fun way to teach colleagues how to teach children. It can be performed by play therapists or nurses. Trained staff can be centralised in one setting, such as children’s outpatients, or dispersed within teams. It’s a simple skill to learn so easy to train and mentor others.”
Dr Yincent Tse, consultant paediatric nephrologist
Overview

This was a quality improvement project to teach children and young people on long term medication how to take tablet medication.

Tablets are safer, more convenient and cheaper than liquid medications. Children and young people (CYP) often remain on liquids due to habit, reluctance to change or staff and parents’ lack of knowledge about switching to tablets.

With funding from the PSC supporting data collection, this initiative started off within one team at the Great North Children’s Hospital Newcastle to train staff and embed a system of converting eligible children to tablet medication. A series of tests of change were made including training, making kit available, publicity and developing team protocols. In three months, 21 out of 25 eligible CYP were successfully converted with added benefit of saving £46,588 per year.

Since then the initiative has spread throughout the children’s hospital and the North East. In a short timeframe it is possible to embed a system to convert children to tablet medication, improving medication, improving the families’ experience of obtaining medication and realising considerable cost savings. We encourage all units to set up pill swallowing training for their patients.

Aims, objectives and scope

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 (eg Nitrofurantoin cost £9 tablets vs. £447 liquid per month). Liquid medications are difficult to dose and can vary in concentration. Dose errors are common, particularly in families with low health literacy and limited English proficiency.

In 1987 HIV medication was only available in tablet form so clinicians had no choice but to teach children from 4 years how to swallow tablets. Yet when we surveyed our nurses and parents of children in our hospital, we found they remain on liquid due to habit, reluctance and staff not knowing how to convert. We therefore set up a system to teach children how to swallow tablet medicines.

Method and approach

Working with families and teams, the PSC created an interactive training package with a training video and comic poster. They ran interactive hour-long training sessions for staff. Using positive reinforcement and play, the trainer sat facing the learner with sweets or dummy capsules filled with sweets of increasing sizes.

Starting with one small team over 12 weeks they embedded a process for children ≥5 years attending complex renal clinics to be converted from liquid to tablet medication unless contraindicated (eg swallowing or cognitive impairment). They overcame practical barriers by placing easily accessible ‘switching kits’ in clinic filled with the necessary dummy pills, awards and certificates. To increase confidence, they 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 processes were standardised (eg how to round doses, pre-screening clinic lists and creating prompts).

Since then, the PSC have taught other teams and showcased the project across the North East and across the UK. This has generated lots of interests as it is simple and the children have lots of fun learning.

Measurement plan

The outcome measures included successful conversion rate, patient and staff feedback and cost savings.

In terms of costs and resources:

  • Cost of consumables are minimal, some sweets and capsules which cost pennies
  • Staff training takes about an hour to run a session – which is lots of fun, then it’s about giving a go with patient
  • Staff time is minimal, about 10-15 minutes per child. In our hospital some wards used play specialists to take this on. Other teams use their nurses. Staff find this to be a fun activity as it all based on play. It becomes part of their everyday work and a skill staff are proud to have
  • Training materials are free to download and use
  • To build a pill school takes some organising and a willingness to try
  • In organisations with children’s wards there is an already keen group of early adopters with nursing staff and play therapists.
Results and evaluation

In the initial test of change in one team, 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 £46,588 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. They subsequently have spread the idea and trained many other teams, including a research team who were recruiting for a study in which swallowing tablets is an inclusion criteria thus allowing children who were previously excluded to be able to partake in rare diseases clinical trials.

Learning points
  • Make learning fun. Learn in teams who normally work together
  • Data collection is not difficult but does need close steerage. Once we had enough cost improvement data it opened doors to organisational leaders to help spread the project
  • Patient and parents involvement at all stages is really helpful and helps drives the project as the improvement transformed their lives and they are keen to share their experiences.
Plans for spreading learning and encouraging adoption

Teaching tablet swallowing is easy. 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. The project has been well embraced by many teams at the Great North Children’s Hospital. Work is being done to create a ‘pill school’ in out patients led by play therapists and nurses. The PSC is negotiating with our regional medical and nursing schools to equip their graduates with this key paediatric skill in their curriculum.

Over 100 multi-disciplinary staff have since undergone training. This project has been presented orally at numerous regional meetings (eg Winner of Yogi QI prize for innovation, Great North Pharmacy Conference, North of England Paediatric Society meeting and AHSN regional Q event) and national meetings (Neonatal and Paediatric Pharmacy Group national conference 2019, British Association for Paediatric Nephrology Annual Conference 2019, British Paediatric Nephrology Nurses conference 2019). Educationally it has been delivered to Paediatric Specialty Trainee training Days and at North East Paediatric Pharmacist Training Day and there are negotiations to embed it into medical and nursing student curriculum in the North East universities. The project has been accepted for publication in Archives of Disease and Child Health, the medical journal for all UK paediatrians.

Contact

Dr Yincent Tse, consultant paediatric nephrologist
Great North Children’s Hospital, Newcastle Upon Tyne
E: [email protected]