Improving the prescribing of palivizumab.

AIM: Palivizumab prevents respiratory syncytial virus (RSV) in children at high risk of severe disease. This paper reviews the use and effectiveness of palivizumab at two tertiary paediatric hospitals (hospitals A and B) in New South Wales, Australia. METHODS: Children prescribed palivizumab during the pre-intervention period, 1 January 2013 until 31 December 2014, were compared with children under 2 years of age who were admitted to paediatric intensive care units (PICUs) with an RSV infection. Eligibility for palivizumab was determined. To improve evidence-based utilisation of palivizumab, a 'streamlined palivizumab individual patient use' (IPU) pro forma was introduced at hospital A during 2015, and its applicability was reviewed. RESULTS: In the 2 years prior to implementing the streamlined IPU, 47 children received palivizumab, with 87% at hospital A. Of the children at hospital A, 32% did not meet the guidelines, and 32% did not complete the course. While 13% of children admitted to PICU for RSV infection were eligible for palivizumab, none received it prior to admission. In 2015, 16 streamlined IPUs were submitted, and 11 patients received palivizumab. Of these patients, 27% did not meet the guidelines, and 63% did not complete the course. Of the children who received palivizumab during the three RSV seasons, one developed an RSV infection, and none were admitted to PICU. CONCLUSIONS: Palivizumab is often prescribed without meeting recognised best practice guidelines, and patients eligible are frequently not prescribed palivizumab. The streamlined IPU, implemented in hospital A, excluded patients who did not meet guidelines. The pro forma needs further refinement, and complementary strategies introduced to improve compliance.

What the FLOQ? A quality improvement project to reduce unnecessary paediatric respiratory viral swabs in a peripheral metropolitan hospital.

AIM: To reduce the number of paediatric respiratory viral swabs (locally referred to as a FLOQ) performed across the authors clinical centre from a baseline of over 800 ($38 000) per year by 25% over 4 months from 6 February 2017 to 31 May 2017. METHODS: A quality improvement project 'What the FLOQ?' (WTF) was instigated from 6 February 2017 to complement the Emergency Department (ED) 'Sensible Test Ordering Process' project from 1 April 2017. Stakeholder engagement across ED and general paediatric staff was sought. Alterations in practice included education of staff, targeted feedback to groups frequently ordering a FLOQ and rationalising patients appropriate for testing. Monthly requests were tallied on a run chart for FLOQs ordered in ED and the paediatric ward. A monthly audit of FLOQs performed on ED-discharged patients was conducted with feedback. RESULTS: Total FLOQ swabs decreased by 55% from 336 (February to May 2016) to 151 (February to May 2017). ED performed 66% less FLOQs from 237 (February to May 2016) to 82 (February to May 2017). There was no increase in the number of FLOQs performed on the paediatric ward February to May 2017. Monthly auditing of ED discharged patients under 2 years with a FLOQ went from 40 to 3%. CONCLUSION: Rationalising patient groups appropriate for testing with targeted feedback and broad stakeholder engagement successfully reduced FLOQs performed by 55%. This has projected savings of over $21 000 by 12 months. WTF has reduced the number of invasive patient procedures performed, benefitting staff and patients. Sustaining this change will be achieved through ongoing staff education on rationalisation criteria and consultant only requests outside of these parameters.

An outbreak of enterovirus 71 in metropolitan Sydney: enhanced surveillance and lessons learnt.

OBJECTIVE: To report the findings of the enhanced surveillance set up in New South Wales in response to the recent outbreak of human enterovirus 71 (EV71) infection. DESIGN AND SETTING: A two-armed enhanced public health surveillance system including statewide emergency department surveillance and clinical surveillance at the Sydney Children's Hospitals Network. PARTICIPANTS: Children aged less than 10 years with suspected or confirmed enterovirus infection. MAIN OUTCOME MEASURES: Epidemiology of the outbreak, including weekly case counts, demographic information, geographic spread of the outbreak, and clinical presentation and progression. RESULTS: Statewide weekly case counts indicate that an epidemic of EV71 infection occurred in NSW from December 2012 until May 2013. Around 119 children were reported with disease severe enough to warrant admission to a tertiary Sydney children's hospital. Cases were spread throughout the Sydney metropolitan area and there is some evidence of geographic migration of the outbreak. Presenting features included fever, lethargy, myoclonus and skin rash. Only 24% of cases presented with classical hand, foot and mouth disease. CONCLUSIONS: EV71 infection is likely to continue to be a public health problem in Australia. Surveillance of routinely collected emergency department data can provide a useful indication of its activity in the community.

Enterovirus 71 outbreak in Northern Sydney, 2013: case series and initial response.

AIM: Enteroviruses are a common cause of childhood disease which may manifest in a variety of ways. Enterovirus 71 (EV71) is a subtype of enterovirus which can cause meningoencephalomyelitis resulting in neurological sequelae including lethargy, weakness, ataxia, sleep myoclonus, urinary retention and, in severe cases, cardiorespiratory collapse due to neurogenic pulmonary oedema. EV71 was responsible for outbreaks in South East Asia in 1997-1998, in Western Australia in 1999 and in Sydney in 2000-2001. In 2013, we are experiencing another EV71 outbreak in Sydney. This study describes the discovery of a new outbreak in Sydney's Northern Beaches, the clinical findings as well as the public health response. METHODS: Thirty-seven children in total presented with presumed EV71 to the Northern Beaches Health Service from December 2012 to April 2013. Most children presented with a prodrome lasting 2-7 days prior to seeking medical attention. Sleep myoclonus was a common presenting sign occurring in 65%. Neurological signs were subtle in the majority of children and were at times missed by clinicians on a child's first presentation. Forty-six per cent of children who presented to Northern Beaches Health Service during this outbreak required a transfer to a tertiary paediatric centre for more intensive care. RESULTS: The public health investigation was important in establishing that the disease was widespread throughout the community and not as a result to exposure to a single child care setting. Identification of risk factors enabled more targeted communication to medical practitioners, child care centres and parents within the local community. CONCLUSIONS: EV71 is in Australia and all clinicians seeing children in primary, secondary and tertiary care centres need to be aware of the disease, the subtle nature of initial symptoms and the potentially devastating consequences.