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Patient Safety Department of Internal Medicine Faculty of Medicine Prince of Songkla University Department of Internal Medicine Faculty of Medicine Prince.

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Presentation on theme: "Patient Safety Department of Internal Medicine Faculty of Medicine Prince of Songkla University Department of Internal Medicine Faculty of Medicine Prince."— Presentation transcript:

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

5 Number of medical ICU admission and intubation : present

6 Self extubation rate in medical ICU: Before intervention

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

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

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

10 LITERATURE REVIEW Patient Safety

11 Sedation: Current Issues Over-sedated 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 Without a means to objectively titrate the level of sedation, patients may be:

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 AgentsMixtureDosagePrecaution 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 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 ScoreDescriptionDefinition 7 Dangerous agitation 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 5Agitated Anxious or mildly agitated, attempt to sit up, calm down to verbal instruction 4LightSedation(Default) Calm and cooperative Calm, awakening easily, follows command 3Sedated 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 1HeavysedationUnrousable Minimal or no response to noxious stimuli, does not communicate or follow commands, weak cough on suction

19 เริ่มให้ยา Bolus injection และ ให้ยาในระดับต่ำที่สุดตาม guideline ทดสอบระดับ Sedation ของผู้ป่วยทุก 30 นาที และปรับยาขึ้น 1-2 ml/hr จนได้ระดับที่ ต้องการ แพทย์สั่งระดับ Sedation ที่ ต้องการ ประเมินความรู้สึกตัวทุก 1 ชั่วโมง ระดับ Sedation มากกว่าที่ต้องการ ระดับ Sedation น้อยกว่าที่ต้องการ ลดขนาดยาลงครึ่งหนึ่ง หรือ หยุดการให้ยา Bolus ยา และเพิ่มขนาดยา อีก 1-2 ml/hr ระดับ Sedation อยู่ ในระดับที่ต้องการ

20 OUTCOMEOUTCOME Patient Safety

21 Self extubation rate in medical ICU intervention

22 BenchmarkingBenchmarking

23 LEARNINGLEARNING Patient Safety

24 LearningLearning • 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 • 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. LearningLearning

26 Patient Safety in cancer patients Oncology nurse driven chemotherapy

27 IMPACTIMPACT Patient Safety

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 No error in chemotherapy given Chemo thera peutic unit Check patient label Check drug and dosage 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

33

34 OUTCOMEOUTCOME Patient Safety

35 Number of patients : Jan - Oct 07 N Total IPD cases2,329 Average IPD cases/day7.8 Total OPD cases5,280 Average OPD cases/day17.5

36 Lagging indicators N Inaccurate dose and drug0 Wrong patients0 Leakage of chemotherapy during injection0 Medical advice postchemotherapy100

37 ภาควิชาและมูลค่าที่มีการยกเลิก หลังเตรียมยา ( มกราคม – มิถุนายน 2550)

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

39 LEARNINGLEARNING Patient Safety

40 • 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. LearningLearning

41 THANK YOU


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