1. Patient Safety Quality Assurance Report: 30th November 2007
Department of Internal Medicine
Faculty of Medicine
Prince of Songkla University
Patient Safety
Quality Assurance Report: 30th November 2007

2. Department of Internal Medicine Patient Safety project
Patient Safety in critically ill patients
Self extubation
Patient Safety in cancer patients
Oncology nurse driven chemotherapy

3. Patient Safety in Critically ill patients
Prevention of self extubation in medical ICU

4. Patient Safety
IMPACT

5. Number of medical ICU admission and intubation : 2544 - present

6. Self extubation rate in medical ICU: Before intervention

7. Why is self extubation important?
Risk of airway injury
Risk of aspiration and VAP
Increased ventilator day
Increased ICU stay
Increased treatment cost
Increased ICU mortality

8. Why is self extubation important?
ICU performance benchmark
Must be zero incidence

9. How could self extubation be reduced?
Patients restrain
ET-tube strapping technique
Relatives education
Reduction of self extubation
sedation

10. Patient Safety
Literature review

11. Sedation: Current Issues
Without a means to
objectively titrate
the level of sedation,
patients may be:
Over-sedated
increased drug costs
delayed weaning
increased ICU length of stay
increased testing
Under-sedated
anxiety and agitation
awareness and recall
post-traumatic stress disorder
increased adverse events
increased use of paralytics
The majority of patients will receive some form of sedation during their stay in an intensive care unit, and for many, this is a critical component of their care regime. However ICU patients are very complex and their needs for sedatives are unpredictable and complicated, and often highly variable.
Sedation challenges in the ICU are well documented and recognized, and even more so in recent years. It is clear that the problems associated with sedation are indeed bipolar, branching into 2 extreme conditions of over sedation and under-sedation -- each with their important consequences.
Over-sedation
Can result in unnecessary costs of sedative drugs, which in some cases can range into hundreds of dollars per patient per day.
When patients are over-sedated, they often experience delayed weaning from mechanical ventilation (MV), which can impose additional costs. Even more importantly, extended and unnecessary time on MV can lead to complications such as ventilator associated pneumonias and the need for tracheostomies.
Extension of MV and other complications can result in increased length of stay (LOS) in the ICU and hospital.
Additionally, when patients do not show signs of waking up when sedation is weaned or discontinued, many of them will be subjected to expensive and unnecessary diagnostic tests to rule out the incidence of a neurological event.
Under-sedation
Can result in patients who are anxious and agitated, and increase the risk of awareness and recall of unpleasant events, even in patients who are receiving neuromuscular blocking agents (NMBAs). These occurrences are far more common than they are in the OR setting. They may also result in long-term sequelae such as Post-Traumatic Stress Disorder (PTSD)
In addition, patients who do not have adequate sedation may receive other classes of drugs, such as NMBAs.

12. Daily interruption of sedative infusion in critically ill patients undergoing mechanical ventilation
Kress. NEJM 2000.

13. Effect of nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia
Quenot. CCM 2007.

14. Effect of nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia
Quenot. CCM 2007.

15. Sedation Use Recommendations
Lorazepam is recommended for sedation of most patients via intermittant IV or continuous infusion (Grade=B)
Triglyceride levels should be monitored after two days of propofol infusion (Grade=B)
Use of sedation guidelines, an algorithm or a protocol is recommended. (Grade=B)
Jacobi J. Crit Care Med 2002; 30(1):

16. Sedation protocol production
intensivist
Critical care nurse

17. Morphine and Midazolam (M&M) combination
Agents
Mixture
Dosage
Precaution
Morphine and Midazolam (M&M) combination
(First line agent)
Morphine 60 mg + Midazolam 30 mg + NSS 60 ml
loading 2-3 ml iv then continuous drip 1-20 ml/hr and 1-3 ml iv prn.
prolonged effect in renal dysfunction
beware of seizure in renal dysfunction due to accumulation of active metabolite of Morphine
Morphine
Morphine 60 mg + NSS 60 ml
continuous drip 1-5 ml/hr and 1-3 m iv prn.
for pain control only
as above
Midazolam
Midazolam 30 mg + NSS 60 ml
continuous drip 1-20 ml/hr
only for sedation
Fentanyl
Fentanyl 500 mcg + NSS 50 ml
continuous drip 0.5 – 5 ml/hr
second line agent for pain control in renal failure patients
Proprofol
Proprofol 200 mg
continuous drip ml/hr and mg iv prn.
second line agent for sedation
check CPK and Triglyceride level if use longer than 5 days
no analgesic effect at all

18. Score Description Definition 7 Dangerous agitation 6 Very agitated 5
Pulling at ET tube, trying to remove catheters, climbing over bedrail, striking to staff, thrashing side by side 6
Very agitated
Does not clam despite frequent verbal reminding of limit, require physical restraints, biting ETT 5
Agitated
Anxious or mildly agitated, attempt to sit up, calm down to verbal instruction 4
Light
Sedation
(Default)
Calm and cooperative
Calm, awakening easily, follows command 3
Sedated
Difficult to arouse, awake or eye open to verbal stimuli or gentle shaking but drift off again, follow simple command 2
Moderate sedation
Very sedated
Arouses to physical stimuli but does not communicate of follow commands, may move spontaneously, eye close 1
Heavy
sedation
Unrousable
Minimal or no response to noxious stimuli, does not communicate or follow commands, weak cough on suction

19. แพทย์สั่งระดับ Sedation ที่ต้องการ
เริ่มให้ยา Bolus injection และ ให้ยาในระดับต่ำที่สุดตาม guideline
ทดสอบระดับ Sedation ของผู้ป่วยทุก 30 นาที และปรับยาขึ้น 1-2 ml/hr จนได้ระดับที่ต้องการ
ประเมินความรู้สึกตัวทุก ชั่วโมง
ระดับ Sedation
มากกว่าที่ต้องการ
ระดับ Sedation
น้อยกว่าที่ต้องการ
ระดับ Sedation อยู่ในระดับที่ต้องการ
ลดขนาดยาลงครึ่งหนึ่ง หรือ หยุดการให้ยา
Bolus ยา และเพิ่มขนาดยาอีก 1-2 ml/hr

20. Patient Safety
outcome

21. Self extubation rate in medical ICU
intervention

22. Benchmarking

23. Patient Safety
learning

24. Learning
Sedation protocol is effective to prevent self extubation in medical ICU.
Sedation protocol did not increase ventilator day and risk of VAP.
The collaborate of critical care nurse and intensivist is the key of success.
The incidence of extubation could possible reach to ZERO.

25. Learning
We should be increase awareness and alertness in isolated room patients.
During period of sedation interruption, critical care nurse must pay more attention to the patients in order to prevent self extubation.
This protocol should be implemented in all ventilator care unit.

26. Patient Safety in cancer patients
Oncology nurse driven chemotherapy

27. Patient Safety
IMPACT

28. Number of cancer patients in medicine department: 2550

29. Medical error in chemotherapeutic patients
Inaccurate dose and drug
Wrong patients
Leakage of chemotherapy during injection
No medical advice postchemotherapy

30. Why chemotherapy error is important?
life threatening complication
Morbidity
Ineffective of treatment
Poor treatment outcome

31. Safety in chemotherapy injection
Check drug and dosage
Check patient label
Chemo thera peutic unit
No error in chemotherapy given
Oncology nurse
Amended injection technique

32. Oncology nurse: job description
Give chemotherapy to hospitalized medical oncology patients
Give medical advice for cancer patients
Instruction and sharing the knowledge of caring in cancer patient to ward nurses

34. Patient Safety
outcome

35. Number of patients : Jan - Oct 07
Total IPD cases
2,329
Average IPD cases/day
7.8
Total OPD cases
5,280
Average OPD cases/day
17.5

36. Lagging indicators N Inaccurate dose and drug Wrong patients
Wrong patients
Leakage of chemotherapy during injection
Medical advice postchemotherapy
100

37. ภาควิชาและมูลค่าที่มีการยกเลิกหลังเตรียมยา (มกราคม – มิถุนายน 2550)

38. Injection technique Old fashion Amended technique
Scalp vein catheter insertion
IV push of chemotherapy
Amended technique
MEDICUT® insertion
Extension tube connection

39. Patient Safety
learning

40. Learning New infusion technique is safe and simple.
Oncology nurse should be implemented in all cases of chemotherapy patients.
New process may be decrease unused drug.

41. Thank you