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Patient Safety Quality Assurance Report: 30th November 2007

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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

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

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