Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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). 8. Pang R, Kong D, deClifford J, Lam S, Leung B. Smart infusion pumps reduce intravenous medication administration errors at an Australian teaching hospital. Journal of Pharmacy Practice 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. 10. Westbrook J, Rob M, Woods A, Parry D. Errors in the administration of intravenous medications 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]. 11. Cousins D, Sabatier B, Begue D, Schmitt C, Hoppe-Tichy T. Medication errors in intravenous 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]. 12. Han P, Coombes I, Green B. Factors predictive of intravenous fluid administration errors in Australian surgical care wards. Qual Saf Health Care 2005;14:179-184. 13. Hertzel C, Sousa V. The use of smart pumps for preventing medication errors. Journal of Infusion Nursing 2009;32(5):257-267.