A Quality Initiative to Improve Appropriate Medication Dosing in Pediatric Patients with Obesity

Abstract

Introduction: Emerging evidence supports the use of alternative dosing weights for medications in patients with obesity. Pediatric obesity presents a particular challenge because most medications are dosed based on patient weight. Additionally, building system-wide pediatric obesity safeguards is difficult due to pediatric obesity definitions of body mass index-percentile-for-age via the Center for Disease Control growth charts. We describe a quality initiative to increase appropriate medication dosing in inpatients with obesity. The specific aim was to increase appropriate dosing for 7 high-risk medications in inpatients with obesity ≥2 years old from 37% to >74% and to sustain for 1 year.

Methods: The Institute for Healthcare Improvement model for improvement was used to plan interventions and track outcomes progress. Interventions included a literature review to establish internal dosing guidance, electronic health record (EHR) functionality to identify pediatric patients with obesity, a default selection for medication weight with an opt-out, and obtaining patient heights in the emergency department.

Results: Appropriate dosing weight use in medication ordered for patients with obesity increased from 37% to 83.4% and was sustained above the goal of 74% for 12 months.

Conclusions: Implementation of EHR-based clinical decision support has increased appropriate evidence-based dosing of medications in pediatric and adult inpatients with obesity. Future studies should investigate the clinical and safety implications of using alternative dosing weights in pediatric patients.

Fig. 1.

Key driver diagram. ADEQC, adverse drug event quality collaborative; CTICU, cardiothoracic intensive care unit; PICU, pediatric intenive care unit; ID, infectious disease; BMT, bone marrow transplant; SBARs, situation, background, assessment, recommendation; PDSA, plan, do, study, act.

Fig. 2.

EHR functionality: example medication order for a patient with obesity. Functionality of the primary intervention included a passive alert alongside the medication order stating the patient has obesity, a hyperlink to our institution’s obesity dosing guideline, and an opt-out functionality that defaults the dosing weight used to the preferred alternative dosing weight.

Fig. 3.

P chart for percentage of appropriate dosing of select medications in patients with obesity. Hospital-wide appropriate dosing of medications (amikacin, gentamicin, tobramycin, acetaminophen, dexmedetomidine, voriconazole, and acyclovir) in obese patients before and after interventions. Intervention A: Implementation of EHR functionality, obesity dosing guideline, and hospital-wide education. Intervention B: Implementation of obtaining heights in the ED, new stadiometers in all ED intake rooms, staff education, and adding a height entry to all electronic ED intake forms.

Fig. 4.

P chart for percentage of appropriate dosing of select medications in patients with obesity excluding acetaminophen orders. Hospital-wide appropriate dosing of medications (excluding acetaminophen) in obese patients before and after interventions. Intervention A: Implementation of EHR functionality, obesity dosing guideline, and hospital-wide education. Intervention B: Implementation of obtaining heights in the ED, new stadiometers in all ED intake rooms, staff education, and adding a height entry to all electronic ED intake forms.

Fig. 5.

Funnel chart of inappropriate dosing by hospital unit/service.