Download Establishing a nurse coordinator role to manage a District Health

Establishing a nurse coordinator role to manage a District
Health Board’s medication safety dataset and lead
intravenous change.
Abstract:
Intravenous therapy has evolved at a rapid pace as a result of both burgeoning technology and
a plethora of clinical practice considerations. 1,2,3,4 Health care organisations face significant
challenges in implementing smart pump technology [medication safety software (MSS)] and
continually adapting practice to meet changes to intravenous best practice guidelines, all while
maintaining a skilled workforce who can deliver an efficient and high level of care. This article
highlights factors that led to the creation of a permanent role of Nurse Coordinator: IV Device
and Practice Management within a New Zealand District Health Board setting, discusses the
key concepts of how the nurse coordinator role has led to the provision of a more standardised
approach to intravenous care and outlines the creation of a number of relevant electronic
learning resources. It also showcases a cost effective approach to updating, maintaining and
managing the dataset for medication safety software.
Background: A history of intravenous therapy within a district health board
setting
Northland District Health Board (NDHB) provides a wide range of health care services covering
both urban and rural environments. It serves a population of approximately 157,420 and
provides services via four hospital sites as well as community settings.5 A total of 328 beds are
available. Prior to 2010 a number of recommendations and decisions were made within the
organisation which highlighted the need to establish a permanent role for IV medication safety
management. One significant issue related to ensuring that the initial dataset embedded within
the GP volumetric pumps in 2008 was evaluated and updated to meet clinical needs.
Furthermore, it was also essential that this was performed in a timely manner to maximise staff
adoption of and adherence with medication safety software (MSS) within their clinical areas.
Frequent correspondence had been received from staff via pharmacy with requests for new
drug listings, alterations and ongoing education but there was no project person assigned to
lead the work. The former staff member had completed
their contract and left the organisation. However, no key
nursing role was available to help progress IV best
practice standards and pump management issues. There
continued to be multiple requests for support regarding
intravenous matters including education and document
revision in response to changes in IV best practice
recommendations. Previously, generic educator roles
included designing IV resource materials for staff use but
staff changes and role revisions resulted in these falling
by the wayside.
History of volumetric pumps and MSS at NDHB
October 2005
A Medication Focus Group was commissioned to undertake an audit and
review of medication errors
May 2006
Medication Focus Group present recommendations
June 2006
Volumetric pumps capable of supporting MSS introduced but MSS functionality not
activated
March 2007
Medication Safety Project Team setup
Two of many recommendations made by the Medication Safety
Project Action Plan were:
•
Implementation of smart pumps with MSS activated; and
•
Standardisation of infusion devices across the organisation
November 2008
MSS dataset installed on volumetric pumps
Discussion: Establishing a dedicated nurse coordinator role
A number of recommendations from the earlier Medication Safety Project: Infusion Devices
report6 were made with a vision to consolidate a consistent work plan around IV matters, device
planning and MSS issues. These included:
•
Establishing a dedicated role whereby information relating to IV therapy could be
evaluated and disseminated across the organisation to foster consistent and safe
practice.
•
Recommending replacement of the ageing fleet of infusion pumps with standard devices
suitable for purpose and including inbuilt MSS.
In April 2010 a secondment was established within the DHB’s Nursing Directorate. This person
was tasked with investigating and addressing the above challenges. Following investigation, a
major drive was instigated to update IV guidelines, design and introduce new electronic
teaching resources, and create a sustainable plan for smart pump management throughout the
organisation.
Establishing a long term MSS and device management plan
Data from a continuous quality improvement audit (CQI) provided by the smart pump supplier’s
medication safety specialist7 showed the following:
Data obtained ranged from 1st Dec 2008 - June 2009
• Days in use: 188
• Instruments in use: 150
• Instruments downloaded: 127
• Infusion starts: 144,621
• Average starts per day: 769
• MSS - drugs selected infusion starts: 66,485
• Infusions started with MSS: 45.97%
The audit revealed that hospital wide 54.03% of all infusions were started without MSS
protection. Other sources have previously found similarly low trends.8, 13 In 2009, the Institute
for Safe Medication Practices 9 released guidelines for safe implementation of smart pump
technology. They noted that smart pumps can decrease administration errors relating to
programming and miscalculated dosing errors. However, the report also warned that should
staff override the MSS, the smart pump software was rendered ineffective. The data was
presented back to the clinical areas and investigated further for factors that could be revised.
The following issues were initially identified as impeding effective MSS use:
1. Staff had used the volumetric device using the mls/hr functionality for over two years
prior to the first MSS dataset being installed. A habit had been created and therefore
required a culture change for staff to use the pumps using the MSS functionality.
2. The MSS dataset did not always align with relevant drug guidelines. Some of the initial
listings had been based on another DHB’s dataset.
3. Multiple drug guidelines were located in different areas of the hospital for the same
medication type, e.g. there were 3 phenytoin guidelines in use. The nuances of each of
these guidelines required more specificity to be included within the dataset for individual
area profile listings.
4. Staff unavailability to review the CQI for 10
months between collection of the data and
commencement of the seconded IV coordinator
role. Staff became despondent as feedback
mechanisms were not in place and therefore
they didn’t see the relevance of using MSS or
reporting issues if no corrective action was
forthcoming. This added to staff frequently overriding the system.
CQI Analysis - June 2009
Hospital wide 54.03% of all infusions
were started without MSS protection
Mls/hr
Westbrook et al 10 highlighted the complex nature of preparing, administering and monitoring
intravenous medication, while also identifying a high risk for serious adverse patient outcomes
and an over-representation of errors with delivery via the intravenous route. Furthermore, they
found that four key error types accounted for 91.7% of clinical intravenous errors. These
included administering at the wrong rate (most frequent error), wrong mixture, wrong volume,
and drug incompatibilities. This study further supports other literature and gives credence to
promoting use of MSS on intravenous devices. 8, 11, 12
Hertzel and Sousa 13 emphasize the need for an analytical approach to be used in conjunction
with the various pump configuration and dataset profiles. Therefore, staff education must
reinforce the fact that smart pump technology cannot be solely relied upon to prevent
medication errors entirely. It is one of a number of safety mechanisms that should be utilized in
the process of preparing and administering IV medication in a safe manner.
MSS alerts by drug showed that six drugs made up 75% of all alerts
Addressing discrepancies within the initial dataset
Several challenges existed with the original dataset. The most common type of discrepancy
found was a high occurrence of nuisance alarms, especially among the six most frequent
medication alerts.
This information triggered a series of changes to decrease the need to override the MSS alarms
while tightening the safety limits, thus strengthening the dataset.
Higher soft alert limits
The fluid and blood listings were revised allowing for higher soft alert levels. These had initially
been set too low for some areas, e.g. patient rehydration post surgery.
Dividing drug profiles by weight range to improve effectiveness of safety limits
Staff in the special care baby unit (SCBU) encountered a hard limit fluid setting equivalent to
day one, hourly fluid requirements. As the daily fluid requirements were calculated on
progressive days it forced the staff to use the mls/hr function outside of the MSS functionality
allowing an excessive rate to be set without an alert.
Drugs with absolute maximum dose limits, e.g. alteplase for stroke 0.9mg/kg maximum 90mg,
can be managed by providing data for patients >100kg and patients <100kg, thus reducing the
risk of administering more than 90mg dose to any patient. This also allowed the dose for the
<90kg weight to be administered using a weight-based dose profile reducing the risk of a
patient receiving too high a dose.
Paediatric fluid listings were split into three different weight ranges achieving safer parameters.
•
<10kg - as a mls/kg/hr option
•
10-20kg weight range with a mls/hr option that defaulted to a fluid maintenance regime
for an 11kg child forcing staff to calculate the correct fluid requirements and increase as
appropriate
•
>20kg weight range option that defaulted to the 20kg weight fluid maintenance
requirements.
Designing the data for a drug to meet one or more specific regimens
Gentamicin listings were divided into Gentamicin 8hrly and Gentamicin DAILY to allow for the
different hard alert parameters required to avoid toxicity.
A specialised paediatric cystic fibrosis profile was created to serve a select group of patients
who required very high dose regimens. This allowed the general paediatric profile concentration
and rate alerts to be reduced since there was no longer a need to allow for patients being
treated for cystic fibrosis.
Separate drug profiles
Longshore et al 4 notes other strategies that improved their drug library included: using preestablished standardised concentrations and adding a clinical training profile for staff education.
We utilised this approach by creating separate comprehensive adult, paediatric and SCBU
training profiles in our dataset revision, ensuring staff could train without distorting data in the
area profile listings.
In addition we added some further profiles that allowed us to tweak data to meet specific needs
in specialist areas that we did want to allow in more generalist areas.
Initial area profiles
•
•
•
•
•
•
•
•
•
•
•
•
CCU
ED Paeds
ED Adult
ICU
ICU Paeds
Maternity
Medical
Orthopaedics
Paediatrics
Renal
SCBU
Surgical
New area profiles were established:
•
•
•
•
•
•
•
•
Community
Med Procedure Room
Renal
Paediatrics – Cystic fibrosis ONLY
Paediatric ICU
Training – Adult
Training – Paediatric
Training - SCBU
Fixed infusion solution concentrations
Many old continuous IV infusion guidelines were developed using complicated mathematical
calculations and infusion solution dilution to allow a rate in ml/h to equate to a dose, say, in
mg/h. With MSS this is no longer necessary as the dose rate can be set and seen at any point
in time on the pump device. Accordingly, where practicable, we have changed to making
infusion solutions in fixed concentrations (rather than variable) using whole ampoules of stock
solution.
Device and software education
Training was provided by the nurse coordinator and company representatives detailing device
functions and mode of action reinforcing concepts such as making use of the training profiles
when teaching, highlighting the capabilities of the MSS and its limitations. Special sessions
providing practical advice on device use were organised for the pharmacist group, new clinical
nurse specialists and educators to update their knowledge so they could continue to educate
users in their respective areas.
Other achievements over the first 18 months of
establishing a nurse coordinator position
Devising and maintaining quality electronic learning resources
Creation of the nurse coordinator role allowed dedicated resource for review of the IV workplace
competency framework. Current IV best practice manuals were assessed and subsequently
removed from circulation, and replaced with newly created electronic learning resources. Larger
DHBs can sometimes allocate this project work to a specific person with an information
technology background, however, in our DHB all required resources needed to be designed and
implemented by the nurse coordinator. The need for a PICC learning resource had been
deemed urgent in a previous report
6
and was completed early in the initial secondment. The
content for each learning resource had to be researched, evaluated and, in many cases,
completely rewritten. Significant help was provided by clinical nurse specialists throughout the
country who generously shared some of their resources to assist progress. Belonging to IVNNZ
and maintaining integral links with other similar minded specialists has also provided support
and direction for the nurse coordinator role. All new learning packages were reviewed via two
internal governance groups. Significant developments include:
•
outlining the revised IV workplace competency process,
•
development of a nurse coordinator homepage on the intranet,
•
creation of a MSS electronic resource, an updated resource kit with PICC procedure
guidelines, blood transfusion guidelines and various other data linked to internal and
external websites.
Staff no longer had to await the availability of an educator to commence their readings or rely
on locating hard copies that may be outdated or inaccessible. A further development was
creation of a medication safety e-learning tool to support enrolled nurses transitioning to their
new scope of practice. This was later expanded to support staff during induction to the
organisation as well as being made available for current staff to access.
New electronic (Moodle) learning resources designed by the nurse coordinator
Intravenous therapy
Port-a-cath
Peripherally inserted central catheters
Epidural analgesia
Safe medication management
Venous cannulation
Pump replacement and standardisation with models fit for purpose
MSS was not available on the previous syringe drivers due to older technology. The biomedical
department reported a significant increase in servicing costs and raised a concern that the
current status quo was not sustainable. A project led by the nurse coordinator enabled planning
for the old devices to be replaced with a new fleet of syringe drivers in February 2012. A
decision to choose the CC syringe driver as the sole device for use in all areas outside of the
theatre environment has eliminated a need for a further general purpose syringe driver to be
purchased. This device was chosen as it allows for pressure monitoring and other advanced
features sometimes required in the critical care environments while also meeting paediatric
delivery needs. Lee 2 also highlighted a need for a coordinated and standardised approach to
device management thereby reducing risk when dealing with infusion therapy and associated
devices.
Standardisation has now allowed for a total of six types of pumps within the organisation, each
with a specific use
•
GP volumetric pumps – IV fluids/blood, high volume medications
•
CC syringe drivers (Feb 2012) – High risk/low volume medications/transportation needs
•
PK syringe driver (Sept 2011) – designated anaesthetic/theatre use only
•
Niki T34 device (March 2011) - designated for subcutaneous delivery only
•
PCAM (Feb 2011) – designated for patient controlled analgesia
•
I-pump – designated for epidural delivery only
Collaboration
Need for wide consultation with other key staff was essential to ensure that the projects
undertaken progressed well. Various committees such as the drugs and therapeutics
committee, assets and capital, and senior management groups were also updated to progress
submissions and obtain consensus.
A joint approach between the nurse coordinator and professional pharmacy advisor has proved
superior when designing and updating MMS datasets. This has enabled both staff to draw on
each other’s expertise and professional contacts. Creating a quality dataset involves a
systematic approach that considers feedback from senior clinicians, educators, managers,
clinical nurse specialists and ward staff ensuring alignment of data and setting of appropriate
device configurations and area specific guidelines. Eliminating either of these roles would result
in an inferior dataset and poor staff acceptance.
Where to from here:
Further CQI analysis will be beneficial to monitor ongoing MSS usage . This has been deferred
currently as replacement of other devices has been allocated a higher priority. In 2011 a major
revision of the medication administration policy and medication audit tool was undertaken and
embedded into the DHB’s clinical knowledge centre (Sharepoint). This provided an opportunity
to write into policy an expectation that staff were to make use of MSS profiles in the relevant
clinical areas. A follow-up snapshot audit using the hospital’s medication administration audit
tool has provided a provisional indication showing improved use of MSS within a number of
wards although further work needs to continue. Further CQI analysis is strongly advised to
extract data and examine developing trends.
The professional pharmacy advisor and nurse coordinator now share joint responsibility for
monitoring and updating datasets. All uploads are conducted onsite independently by the nurse
coordinator with the biomedical department supporting retrieval and rotation of the individual
devices. This has resulted in saving the DHB a significant amount of money annually as there is
now no need to contract external help for the upload process on a continual basis. The
timeframes for future dataset uploads are aligned with annual service checks wherever
possible. This maximises efficiency and prevents the need to recall the total fleet of pumps
more often than necessary as it involves significant time and potential clinical disruption. Any
organisation investigating purchasing new devices with MSS would be wise to consider systems
that utilise wireless technology. Frequent and timely updates to datasets can then take place
with ease at any time rather than having to wait for the next manual upgrade that could
otherwise be 6 to12 months away. A significant amount of the nurse coordinator’s time
continues to be required on an ongoing basis to revise and edit the dataset, and locate and
upload each device. This needs to be allowed for within each annual work plan.
Conclusion:
In 2010 there were multiple issues requiring urgent attention relating to infusion devices. This
provided a unique opportunity to upgrade and standardise the various devices throughout the
four hospital sites within the DHB. A total of six standard types of device are now utilised within
the organisation. Each has a clearly differentiated use to maximise clinical safety.
Five of these devices now meet the original objective of having some form of medication safety
software embedded on all intravenous and associated devices. The 6th device suitable for
epidural infusions is awaiting the outcome of a tender process.
Staff need to be provided with high quality education regarding MSS and the devices being
used, while also supported to maintain IV best practice. Creating and maintaining medication
safety datasets, multiple learning resources and the supporting policy involves a multifaceted
approach to achieve maximum practicality and clinical usefulness. It also requires significant
time, energy, and dedication supported by appropriate resources to maintain a sustainable
approach. A role such as the nurse coordinator position can provide clarity, direction and
education while ensuring updated MSS datasets are progressed in a cost effective manner.
References:
1. Lavery I. Intravenous practice: improving patient safety. British Journal of Nursing 2011;
(Intravenous Supplement) 20(19):S13 - S19.
2. Lee P. A team approach to identify and manage risk in infusion therapy. British Journal of
Nursing 2010; (Intravenous Supplement) 19(5):S12 – S18.
3. Scales K. Intravenous therapy: a guide to good practice. British Journal of Nursing 2008; (IV
Therapy Supplement) 17(19):S4-S12
4. Longshore L, Smith T, Weist M. Successful implementation of intelligent infusion technology in a
multihospital setting. Journal of Infusion Nursing 2010;33(1):38-47.
5. Northland District Health Board website http://www.northlanddhb.org.nz [Accessed Jan 4, 2012}
6. Dennie D. Medication Safety Project: Infusion Devices Project Report and Closure Document,
Northland District Health Board 2009 (unpublished).
7. Antoniazzi V. Guardrails® CQI Event Reports Summary Northland DHB, CareFusion 2009
(unpublished).
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and Research 2011;41(3):192-195.
9. Institute for Safe Medication Practices. Proceedings from the ISMP summit on the use of
smart infusion pumps: Guidelines for safe implementation and use. 2009.
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in hospital and the role of correct procedures and nurse experience. Qual Saf Healthcare
2011;20:1027-1034 [Accessed from qualitysafety.bmj.com Nov 30, 2011].
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drug preparation and administration: a multicentre audit in the UK, Germany and France. Qual
Saf Healthcare 2005;14:190-195 [Accessed from qualitysafety.bmj.com Jan 21, 2012].
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Australian surgical care wards. Qual Saf Health Care 2005;14:179-184.
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Nursing 2009;32(5):257-267.