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Published on: January 17, 2011
Practice Change From Intermittent Medication Boluses to Bolusing From a Continuous Infusion in Pediatric Critical
Jessica L Hochstetler1, A Jill Thompson2, Natalie M Ball3
1Department of Pharmacy, Texas Children's Hospital, Houston, TX.
Insights
Implementing a guideline to administer bolus medications from continuous infusions in Pediatric Intensive Care Units (PICUs) significantly reduced the time to start a bolus dose and improved nursing satisfaction. This change also optimized medication use without compromising patient safety.
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.
Objectives:
To determine whether implementing a guideline to bolus medications from continuous infusions in PICUs affects nursing satisfaction, patient safety, central line entries, medication utilization, or cost.
Design:
This is a pre- and postimplementation quality improvement study.
Setting:
An 11-bed ICU and 14-bed cardiac ICU in a university-affiliated children's hospital.
Patients:
Patients less than 18 years old admitted to the PICU or pediatric cardiac ICU receiving a continuous infusion of dexmedetomidine, midazolam, fentanyl, morphine, vecuronium, or cisatracurium from May 2015 to May 2016, excluding November 2015 (washout period), were eligible for inclusion.
Interventions:
Change in practice from administering bolus doses from an automated dispensing machine to administering bolus medications from continuous infusion in PICUs.
Measurements And Main Results:
Timing studies were conducted pre- and post implementation in 29 and 26 occurrences, respectively. The median time from the decision to give a bolus until it began infusing decreased by 169 seconds (p < 0.01). Nursing satisfaction increased from 19.3% pre- to 100% post implementation. Safety was assessed via barcode scanning compliance, which decreased by 1.4% for patients and 1% for medications, and smart pump limit overrides. The percentage of infusion pump bolus overrides increased as expected, with the majority (99%) of these exceeding soft maximum limits by less than two-fold. Central line entries were unaffected post implementation. To assess medication utilization, a total of 50 patients in each intervention group were selected for retrospective chart review. Daily fentanyl boluses increased from one to three (p = 0.021). However, midazolam infusion dose and fentanyl infusion duration decreased (p = 0.026 and p = 0.005, respectively). Medication utilization was otherwise unchanged post implementation (p > 0.05). Annualized cost avoidance was $124,160.
Conclusions:
Implementation of bolus medications from continuous infusion in PICUs significantly decreased time to begin a bolus dose and increased nursing satisfaction. The practice change also improved medication utilization without negatively impacting patient safety.
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