Download Balancing Medication Safety with Door to Needle Time

Balancing Medication Safety
with Door to Needle Time
Melissa S Baxter, Pharm.D., BCPS
Kaleida Health
Buffalo General Medical Center/
Gates Vascular Institute
Buffalo, NY
Presenter Disclosure Information

Melissa S Baxter, Pharm.D., BCPS
Balancing Medication Safety with Door to
Needle Time

Financial Disclosure:



No relevant financial relationship exists
Unlabeled/Unapproved Uses Disclosure:

Use of alteplase in acute ischemic stroke in the 3 –
4.5 hour window
Objectives


Understand the importance of establishing a set
flow for a stroke patient including the use of a
time-out and procedure record for
nursing/pharmacy to ensure proper preparation
and administration of alteplase
Establish best practice through a systematic
review of your procedure and equipment to
identify the barriers in administering an accurate
dose of alteplase.
When dosing alteplase, which
weight does your institution most
frequently use?
1.
2.
3.
4.
5.
6.
Estimated weight from family
or patient
Actual weight using a
standing scale
Actual weight using a weight
cart when patient just arrives
and is fully clothed
Actual weight after patient
has had most heavy pieces
of clothing removed
Old weight from record
Other/I don’t know
17%
1
17%
2
17%
17%
3
4
17%
5
17%
6
Flow of Stroke Patient



Ambulance/Walk-ins/Helicopter meet at Triage
ESI (Name/Height/Weight/allergies) is completed
Patient moves to stroke alcove

ED MD:



Completes initial exam and NIHSS and pages stroke team with
name and NIHSS
Orders diagnostics and imaging
ED NURSES:


Two large bore IV’s are established, patient is placed on cardiac
monitor, and pulse ox monitor
Blood work is sent


CBC, CMP, PT/INR/aPTT, troponin-I, CK
Patient is rolled to CT on EMS cart or wheelchair
Flow of Stroke Patient

STROKE team is activated by the ED MD stroke
page




Non-contrast CT of head is completed first to r/o
bleed
CT perfusion study and CTA is completed next
Patient is moved from CT scanner to a zeroed
weight cart


Team meets in CT area
Most heavy items have been removed from patient
Weight is written on bed sheet
Where is alteplase prepared at your
institution?
1.
2.
3.
4.
5.
6.
ED Pharmacy Satellite
Pharmacy, located in close
proximity to ED
Pharmacy, located > 4 floors
or in another building from
ED
Bedside with active
pharmacy participation
Bedside by nursing
Sent by pharmacy in
pneumatic tube system
17%
1
17%
2
17%
17%
3
4
17%
5
17%
6
HIGH ALERT MEDICATIONS

Alteplase is defined as a high-alert medication by the
Institute for Safe Medication Practices (ISMP)


High alert meds bears a heightened risk of causing significant
patient harm when they are used in error
High-alert medications require special safeguards to be put in
place to reduce the risk of errors
Current State of Practice:
 In many institutions the pharmacy prepares and
dispenses alteplase given its high-alert status.
 This can lead to significant delays in administration of
alteplase.
ISMP
DTN
Flow of Stroke Patient

Call is made to partner nurse that patient is an alteplase candidate


Alteplase is pulled from locked medicine cabinet in the ED by ED
pharmacist or ED nurse
Patient is rolled to ED
BEST PRACTICE STRATEGY:


The AHA/ASA through Target: Stroke has published 10 best practice
strategies to help achieve a door to needle (DTN) time of 60
minutes or less in at least 50% of all alteplase eligible patients.
Best practice strategy #8 is: Rapid Access to alteplase.

Under this point they advise that alteplase "should be readily available
in the emergency department or CT scanner area (if CT scanner is not
located in the ED).”
At your institution how is the bolus
prepared/given?
1. Drawn up in a
syringe and given by
MD
2. Drawn up in a
syringe and given by
RN
3. Delivered by pump
4. Other
5. I don’t know
20%
1
20%
20%
2
3
20%
4
20%
5
At your institution how is the 60 minute alteplase infusion
prepared/given?
1.
2.
3.
4.
5.
The discard quantity is removed
from the 100 mg vial, then the
vial is spiked with an infusion set
and hung
The discard quantity is not
removed from the 100 mg vial,
then the vial is spiked with an
infusion set and hung
The infusion is drawn up and
put in an empty PVC bag, we
use 100 mg vials
The infusion is drawn up and
put in an empty PVC bag, we
use 50 mg vials
20%
20%
20%
2
3
20%
20%
I don’t know
1
4
5
BASIC SAFEGUARDS

Remove Unused Quantity/Discard Volume to
avoid an overdose



Or draw up quantity to be infused and place in an
empty PVC bag
Prime primary set of tubing with alteplase so
that infusion starts immediately
 Delay in therapy has been shown to have
worse outcomes
Use pump library software with guardrails
 To avoid administering a medication too
quickly or too slowly
 To avoid an overdose or an under dose
Flushing/Clearing of the Line
Dilemma



If using a standard infusion pump
 Primary infusion set tubing priming volumes vary
 May be ~10-25 ml, every pump/site has different
volumes
 This volume must be given slowly avoiding a quick
“re-bolus” during the clearing of the line
Total volume of 60 minute infusion is not a fixed volume
and varies based upon the patients weight
 ~ 30 to 81 ml
 In smaller patients the majority of the infusion may
be in the primed tubing
There is not another medication like this given in the adult ED
Overfill Volume Dilemma

100 mg vials contain up to 10% overfill per
manufacturers allowances

100 ml vials dose prepared at bedside







Bolus removed by syringe
Infusion measured with syringe(s) and infusion placed in 100 ml
empty PVC bag
Unused quantity remains in vial
We measured 30 “unused quantities” after alteplase was
administered to verify overfill volumes
Range of overfill 2.4 – 8.4 ml
Mean 5.6 ml
NOTE: During preparation, some product was lost due to
the large hole made by the piercing pin.
Addressing The Problems

Goal is to
 Stop the infusion when the alteplase dose to be
administered has completely emptied into the
tubing
 Don’t be tempted to get every last drop from the
100 mg vial
 If discard volume is not removed this step will
catch that
 To avoid administering overfill
 But the tubing is full
 Alteplase is still in drip chamber
 This prevents air from getting into the cassette
 At this point switch the near empty 100 mg vial with a
50 ml bag of NS and resume infusion at the previous
rate of the alteplase infusion
The Solution: 2 Step Pump
Programming




This can be safely and reliably accomplished by altering the volume
to be infused
Pump Step 1:
 Enter your rate in mg/hour
 i.e. 81 mg/hour
 Alter the volume to be infused
 Subtract the priming volume of tubing from your 60 min
infusion volume
 i.e. 81 ml – 20 ml = 61 ml
This will call the nurse back to the pump to make the switch to NS
prior to air getting into the cassette.
Pump Step 2:
 Resume at previous rate in mg/hour
 i.e. 81 mg/hour
 Set volume to be infused at a minimum to clear the lines
 i.e. 25 ml
Flushing/Clearing of the Line
Dilemma

Syringe pumps


Utilize microbore tubing and have minimal volumes to
flush at the end of the infusion (~1-2 ml max)
Allow for infusion of up to 60 ml at a time



1 – 2 syringes can be used to infuse total volume
OK to flush 1 – 2 ml
We currently do not have syringe pumps…
TIME OUT RECORD
PROCEDURE RECORD
PROCEDURE RECORD
PUMP STEP 1
Directions
PUMP STEP 2
Directions
ADVERSE REACTION
RESUMING INFUSION
Recommendations to Overcome
Barriers





Obtain patients actual weight when heavy items have
been removed
Include pharmacy in the stroke team notification system
so they can mobilize to the ED to prepare the alteplase
Store alteplase in the ED in a locked medicine cabinet or
prepare in the ED pharmacy satellite pharmacy
Consider drawing up bolus and infusion to ensure
delivering precise doses, avoiding opportunities for
overdose
Develop a detailed procedure record with your
institutions process for alteplase preparation and
administration


Utilizing a 2 step pump process or use of syringe pumps
Educate, Educate, Educate…
QUESTIONS ???

Please email me at
[email protected]