Update to the Minimum Requirements for Core Competency in Pediatric Hospital Pharmacy Practice

Background

Pediatric patients are not merely small adults when it comes to medication selection, dosing, and administration. They undergo significant growth and physiologic changes over time, resulting in variations in pharmacokinetic and pharmacodynamic parameters. Additionally, pediatrics is a heterogeneous population and can include individuals of varying weights and sizes, from the premature infant weighing 600 g to the adolescent athlete weighing several hundred pounds. As a result of legislative actions for pediatric drug development and research, significant progress has been made with regard to the number of medications that have been “formally” studied in the pediatric population and the timeliness of study initiation. These efforts have resulted in more than 600 medications containing new pediatric information in labeling since 1997.¹ Although improving, there is still a need for pediatric studies to determine efficacy, optimal dosing, pharmacokinetics, or adverse effect profiles of many medications. Although the number of medications with pediatric labeling has increased, when studies in neonates, infants, children and/or adolescents are lacking, common practice is to extrapolate information from adult studies; hence, off-label prescribing is still commonplace. Reported rates of off-label medication use vary and are influenced by many factors, including practice setting and patient age.^2–6

The Joint Commission recommends that pharmacists with pediatric expertise be available or on call at all times for the care of hospitalized pediatric patients and should be assigned to high-risk areas, including the neonatal intensive care units, pediatric critical care units, and pediatric hematology/oncology units.⁷ Unfortunately, the availability of pharmacists with pediatric expertise remains limited. Although colleges of pharmacy provide varying amounts of didactic and clinical hours in pediatrics, the exposure across programs is inconsistent and leads to variability in the knowledge, skills, and perceptions of new graduates toward the provision of care to pediatric patients. In a survey by Prescott et al,8 the mean number of didactic hours related to pediatric topics in Doctor of Pharmacy programs was 21.9 ± 22.9 hours, with a range of 1 to 153 hours. A limited number of pharmacists pursue formal advanced training in pediatrics through completion of residencies or fellowships, which are optional following licensure. Currently, there are about 49 first-year postgraduate pharmacy residencies (postgraduate year [PGY]-1) and 66 American Society of Health-System Pharmacists–accredited second-year postgraduate residency (PGY-2) programs between free-standing and non–free-standing children's hospitals.⁹ Training and competencies around pediatric patients may be limited in residency programs not associated with children's hospitals, depending on the institution. In 2015, the Pediatric Pharmacy Association (PPA) published a position paper regarding minimum core competency for those in pediatric pharmacy practice.¹⁰ This paper serves as an update.

Rationale and Recommendations

As a result of the limited number of pharmacists formally trained in pediatrics, extensive on-the-job training is often necessary to achieve a minimum level of competency for hospital pharmacists who will care for neonates, infants, and children. This is in addition to training focused on the development of general clinical and organizational skills, such as those used in the pharmacists' patient care process, which is applicable across all ages of patients and pharmacy settings.¹¹ Any pharmacist caring for pediatric patients in a hospital setting should demonstrate proficiency in core knowledge and skills before practicing independently. Pharmacists who have not completed residency training in a pediatric facility may have to gain this minimal level of competency through institution-based on-the-job training programs. Currently, there are no suggested minimal competencies for entry-level pharmacists caring for hospitalized children. Table 1 provides suggested topics for skill and knowledge development for entry-level pharmacists caring for hospitalized pediatric patients. Although this is not an exhaustive list, it may give employers some guidance on content to include in their programs. Employers should evaluate what services their institutions offer and try to match their minimal competencies to encompass those areas. For example, an institution whose sole pediatric population is in the neonatal intensive care unit should direct their training to the minimal competencies necessary to care for neonates.

Table 1. Suggested Knowledge Topics and Skills for Pharmacists Caring for Hospitalized Pediatric Patients

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Various training models could be used to gain competence in pediatric pharmacy practice. Possible options include self-directed learning modules, instructor-led learning, continuing education programming, experiential learning with a PGY-2–trained pediatric pharmacist, and case- or skill-based activities. Examples of some of these strategies have been published.^12–14 Each of these approaches could involve the use of pre- and post-assessment tools to gauge the learner's understanding and ability to apply the material. Table 2 includes a list of resources that employers can use to develop training modules. Alternatively, these can be made available to entry-level pharmacists for self-directed learning. Professional organizations, such as the PPA, the American Society of Health-System Pharmacists, and the American College of Clinical Pharmacy, provide pediatric-specific programming, pediatric resources, and certificate programs that could be used by an institution or pharmacist individually or in addition to an institution's training modules.

Table 2. Suggested Resources for the Development of Pediatric Pharmacy Competencies

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Table 2. Cont'd

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Conclusion

Most entry-level pharmacists receive limited formal training in pediatric pharmacotherapy within their Doctor of Pharmacy curricula or via a PGY-1 that is not based in a children's hospital. Based on the pediatric population within their institutions, employers should establish a minimal level of competency for entry-level pharmacists caring for hospitalized pediatric patients. The PPA acknowledges that these minimal competency training programs are essential. However, at this time, PPA cannot endorse one program over another. The selection of a training program must be based on the institution's patient demographics, services offered, resources available, and time allotted for training programs.