Practice Change From Intermittent Medication Boluses to Bolusing From a Continuous Infusion in Pediatric Critical...

Area of Science:

• Pediatric critical care medicine
• Quality improvement initiatives
• Pharmacology and therapeutics

Background:

• Continuous infusions are common for medications like dexmedetomidine, midazolam, fentanyl, morphine, vecuronium, or cisatracurium in Pediatric Intensive Care Units (PICUs).
• Current practices for administering bolus doses may involve delays or inefficiencies.
• Optimizing medication administration is crucial for patient safety and efficient care in PICUs.

Purpose of the Study:

• To evaluate the impact of a new guideline for administering bolus medications from continuous infusions in PICUs.
• To assess changes in nursing satisfaction, patient safety, central line entries, medication utilization, and cost following the guideline implementation.

Main Methods:

• A pre- and post-implementation quality improvement study was conducted in a university-affiliated children's hospital.
• The study included patients under 18 receiving specific continuous infusions in the PICU or pediatric cardiac ICU.
• Key metrics included time to bolus administration, nursing satisfaction surveys, barcode scanning compliance, infusion pump overrides, central line entries, medication utilization patterns, and cost analysis.

Main Results:

• The median time to begin a bolus dose decreased significantly by 169 seconds (p < 0.01).
• Nursing satisfaction increased dramatically from 19.3% to 100%.
• While barcode scanning compliance saw a slight decrease, infusion pump overrides remained within safe limits; central line entries were unaffected. Fentanyl boluses increased, but midazolam infusion dose and fentanyl infusion duration decreased, indicating optimized utilization. Annualized cost avoidance was $124,160.

Conclusions:

• Implementing a guideline to administer bolus medications from continuous infusions in PICUs is effective in reducing administration time and enhancing nursing satisfaction.
• This practice change optimizes medication utilization, including increased fentanyl boluses and decreased infusion durations for certain agents.
• The study demonstrates that this quality improvement initiative can enhance efficiency and satisfaction without negatively impacting patient safety metrics.