Download A Guide to help you implement the safer use of intravenous

‘Safer use of intravenous gentamicin
for neonates’ how-to guide
Why do we need an alert?
• Used in 89 per cent of neonatal units
• Over 500 patient safety incidents reported to NPSA
in 2008/2009
• Side effects include vestibular and auditory
damage, and nephrotoxicity
• Narrow therapeutic range necessitates regular
monitoring of blood serum concentrations
Gentamicin pharmokinetic
information
Gentamicin is a broad spectrum aminoglycoside
antibiotic which is widely used in the treatment of
neonatal infection. It is not absorbed intestinally and
therefore is given by injection. It is associated with a risk
of kidney damage and hearing impairment. Adverse
effects are particularly associated with patients with poor
renal function and where higher gentamicin blood levels
and longer duration of therapy have been used.
Neonatal Nurses
Association
5 units
nationally
piloting
6 additional
units as
controls
8 weeks of
data
PSA
NPSA’s RLS
RCA of
incidents
National
survey
Literature
review
Expert
working
group
PILOT
COLLABORATION
EVIDENCE
Background to alert development
What does the alert say?
Local protocol
Use care
bundle
PDSA cycle
Measurement
Training
• A local gentamicin protocol must be available
• Use the four elements of the care bundle
• Use small cycles of change with a sample of patients
• Measure care bundle compliance daily
• All relevant staff should be provided with applicable training
Develop a local gentamicin protocol
Local protocol
Use care
bundle
PDSA cycle
Measurement
Training
• A local protocol is available that
clarifies:
• The initial dose and frequency of
administration
• Blood level monitoring requirements
• Arrangements for subsequent dosing
adjustments based on blood levels
taken
Ensure local policies include bundle
Local protocol
Use care
bundle
PDSA cycle
Measurement
Training
24-hour clock
•24-hour clock
format should be
used when
prescribing
•Unused time
slots in
prescription
administration
record should be
blocked out at
time of dosing to
prevent wrong
time dosing
Coloured
apron
•Interruptions
during the
preparation and
administration of
gentamicin
should be
minimised by the
wearing of a
disposable
coloured apron
by staff to
indicate that they
should not be
disturbed
Doublechecking
•A doublechecking prompt
should be used
during the
preparation and
administration of
gentamicin
Dose within
one hour
•The prescribed
dose of
gentamicin
should be given
within one hour of
the prescribed
time
Double checking prompt
Local protocol
Use care
bundle
PDSA cycle
Measurement
Training
PDSA cycle applied to gentamicin
Local protocol
Use care
bundle
•Share your results with
your staff and senior
leaders
•Implement identified
actions arising from your
data analysis
•Do we understand the
measures we are using?
•Who will analyse the data?
•How often will data be
analysed?
Act
Plan
Study
Do
PDSA cycle
Measurement
Training
•Analyse the data at
monthly data review
meetings
•What elements of the care
bundle need addressing?
•Ensure compliance charts,
audit charts and doublechecking prompts are all
available
•Collect data
Add more patients after each cycle
Local protocol
Use care
bundle
PDSA cycle
Measurement
Training
• Start the actions in the alert for one
patient and move through the PDSA
cycle
• When your run chart shows at least
80 per cent compliance add more
patients and start the cycle again
• This process should be repeated
from one patient, to three, to five,
etc. (this is the 1:3:5 approach)
Three steps to measurement
Local protocol
Fill out compliance chart (appendix A) after each
administration of gentamicin
Use care
bundle
PDSA cycle
Use above compliance charts to populate audit
charts (appendix B)
Measurement
Training
Use above weekly audit charts to populate
extranet on a monthly basis
Complete the compliance chart
Local protocol
Use care
bundle
PDSA cycle
Care bundle
compliance
chart
Care bundle
daily audit
chart
Measurement
Training
Extranet /
run chart
243 128 4627
01/01/2010
16.07
Complete the compliance chart
Local protocol
Use care
bundle
PDSA cycle
Care bundle
compliance
chart
Care bundle
daily audit
chart
Measurement
Training
Extranet /
run chart
Fill out the audit chart and totals
Local protocol
Use care
bundle
PDSA cycle
Care
bundle
compliance
chart
Care
bundle
daily audit
chart
Measurement
Training
Extranet /
run chart
Upload audit totals on the extranet
Local protocol
Use care
bundle
PDSA cycle
Care bundle
compliance
chart
Care bundle
daily audit
chart
Measurement
Training
Extranet /
run chart
From the daily
audit chart
Upload audit totals on the extranet
Local protocol
Use care
bundle
PDSA cycle
Care bundle
compliance
chart
Care bundle
daily audit
chart
Measurement
Training
Extranet /
run chart
Helpful resources
Local protocol
Use care
bundle
PDSA cycle
Measurement
Training
• In addition to these slides you can
also expect the following resources
to aid in your implementation:
• Instructional Webinar presentations
• FAQs published on the website
• Resources on PDSA cycles and
measurement from the Patient Safety
First and 1000 Lives campaign websites
Therapeutic drug monitoring: why
do it?
• Prevent drug toxicity
• Ensure drug efficacy
Principles of therapeutic drug
monitoring
Understand
what you are
measuring
pre-dose trough
concentration
post-dose peak
concentration
checking efficacy
and/or clearance
Check when
you should be
taking levels
Interpret the
results
leave the dose as is
adjust the dose and/or
the dosing interval
question if you need
to resample and, if so,
when
Communicate
and document
your actions
and escalate
any concerns
if necessary
Be sure to follow your local gentamicin policy when progressing through the above principles
Support with the measurement
extranet
• Patient Safety First Office: 020 79279569 or
www.patientsafetyfirst.nhs.uk
• 1000 Lives Office (Wales): 029 20827651 or
www.1000livescampaign.wales.nhs.uk or the
1000 Lives Campaign contact for the Health
Board
Queries about the alert
• Please email [email protected] or
call 020 79279514