SE1 EO b: Clinical Nurses are involved in interprofessional decision-making groups at the organizational level.

Transcription

1 Structural Empowerment: Professional Development SE1 EO b: Clinical Nurses are involved in interprofessional decision-making groups at the organizational level. Provide one example, with supporting evidence, of improvements resulting from the contributions of clinical nurses in interprofessional decision-making groups at the organizational level. Background/Problem: Nicardipine is a calcium channel blocker medication used to treat uncontrolled or essential hypertension, angina, and central nervous system spasm. It is administered via a large volume infusion pump in the Adult and Pediatric Intensive Care Units, Emergency Department, the Operating Room, and the Cardiac Catheterization Lab. At Massachusetts General Hospital (MGH), both large volume and micro-infusion pumps are equipped with pump libraries that should provide a safety guardrail for medication administration. The drug library entry for each drug has set low and high dose limits. Some of these limits are soft, which means they can be over-ridden; and the others are hard limits and cannot be by-passed. When a dose that falls outside these limits is programmed into the pump, it prompts a message that indicates that the dose is above or below the limits. Jennifer Albert, RN, CCRN, is a Clinical Nurse in the Ellison 4 Surgical Intensive Care Unit, a member of the Medication Education and Approval Committee (MESAC), and Chair of MESAC s Safe Administration Sub Committee Infusion Pump Team. In late August 2015, she realized that the large volume pump drug library for nicardipine did not reflect the standard dosing policy and practice for this medication. Albert made this discovery as she reviewed the Continuous Quality Improvement (CQI) data obtained from the large volume pumps. As part of her work on the MESAC Pump Subcommittee, she routinely reviewed the pump CQI data and noted that the administration of nicardipine was resulting in a significant number of soft dose limits over rides. In fact, approximately 90% of administered doses of this medication were in excess of the upper soft dose limit. At the time the pump library entry for this drug was developed, the upper soft dose limit alarm was set at 5 mg/hr, which was consistent with both MGH and national guidelines for a starting dose of nicardipine. However, this setting did not take into consideration that the drug was routinely ordered and administered at doses above 5 mg/hr, and often up to 15 mg/hr, to achieve the desired response. As a result, every time a dose greater than 5 mg/hr was ordered and the pump set accordingly, the pump alarmed audibly and provided a message indicating that the desired dose was beyond the upper soft dose limit. In order to administer the drug, the nurse was required to override the upper soft dose limit. Thus, clinical nurses constantly encountered the override alarm and alert when titrating this medication. Albert observed that the act of overriding the safety guardrails was a frequent occurrence when administering this medication. This defeated the purpose of override alarms and alerts which should occur infrequently and for unusual

2 circumstances or doses that are truly out of the usual or expected range. She was aware of the Joint Commission s Sentinel Event Alert, Medical device alarm safety in hospitals (Issue 50, April 8, 2013) which reported... that between 85 and 99 percent of alarm signals do not require intervention, such as when alarm conditions are set too tight... This alert also reported that while multiple contributing factors can be identified for every sentinel event, alarm fatigue is the most common contributing factor. Albert was also aware of the 2014 Joint Commission s National Patient Goal (NPSG) # 6, the National Patient Goal (NSPG) on Alarm Management. Two key aspects of this goal provided support for changing the nicardipine drug library. First, NSPG # 6 stated that the resulting noise and displayed information tends to desensitize staff and cause them to miss or ignore alarm signals or even disable them. Additionally, NSPG # 6 pointed out that...settings are not set at an actionable level, and alarm limits that are too narrow. Element A2 of the goal put forth the expectation for hospitals to determine whether certain alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue. Element A3 required that policies and procedures be developed to address the need for clinically appropriate settings for alarm signals. Goal Statement: The primary goal of Albert s work was to reduce the frequency of inappropriate upper soft dose limit override alarms, considered a contributing factor to alarm fatigue, as outlined in the Joint Commission National Patient Goal # 6. The purpose of this NPSG goal was to create a practice environment whereby nurses do not become desensitized to the importance of treating all alarms with equal importance, knowing that all unnecessary alarms have been reduced. Intervention(s)/Initiative(s)/Activities: In October of 2015, Albert discussed her observations and the data with the pharmacists on the MESAC Pump Sub-Committee, Elisabeth Mitchell, RPh and Lisa St. Arnaud, RPh. That led to benchmarking with other similar hospitals being conducted by Kristen Tuiskula, RPh, one of the MESAC pharmacists in November of The benchmarking confirmed that our pump settings were not appropriate for the standard dosing. Following review of the pump CQI data, the medication guideline, and benchmarking with similar institutions, there was consensus that the pump drug library should be revised to be consistent with clinical practice, such that the upper soft alarm override limit be set at 15 mg/hr. Albert made a formal change request by completing a Large Volume Pump Library Change Request Form and submitting it to MESAC for review on December 4, She attended the January 5, 2016 meeting of the MESAC Executive Committee to provide further explanation of the request and answer questions. The request was approved at that meeting. Albert then initiated the process of up-dating the pump library which was done by a wireless up-grade at MGH. Albert was responsible for all related communication and coordination. The wireless up-grade of the revised pump library for nicardipine took place on January 6, 2016, and the official practice change went into effect on January 11, 2016.

3 Participants: Medication Education and Approval Committee (MESAC) Name/Credential Title Department/Unit Patrick Adams, RN Senior Specialist Office of Compliance Dena Alioto, RPh Senior Director- Quality, Pharmacy Administration, Education, and Compliance Jennifer Albert, RN, CCRN Clinical Nurse Ellison 4 SICU Paul Arnstein, RN, PhD, Clinical Nurse Specialist Patient Care Services NP-C Nancy Balch, RPh Senior Pharmacist Emergency Department Kathryn Beauchamp, RN, Clinical Nurse Specialist Bigelow 6 PICU MSN, CCNS Clare Beck, RN, BSN Clinical Nurse Ellison 4 SICU Theodore Benzer, MD Chair- Quality and Emergency Department Marcy Bergeron, MSN, Director of Nursing and Primary Care ANP-BC Clinical Operations Gayle Blouin, RPh Senior Pharmacist Pharmacy Jaime Chang, MD Physician Department of Medicine Victor Chiappa, MD Clinical Educator Department of Medicine Christopher Coley, MD Assistant Chief for QA Department of Medicine Colleen Collins, RPh Medical Pharmacist Pharmacy Allegra DePietro, RPh, Manager Nuclear Pharmacy Services BCNP Joanne Empoliti, RN Nursing Director Ellison 7, Surgical Unit Anthony Fatalo, RPh Study Pharmacist Pharmacy Kathleen Finn, MD Physician Department of Medicine Christopher Fortier, Director MGH Pharmacy PharmD Debra Frost, RN, DNP Staff Specialist Patient Care Services Office of Quality and Michele Golden Staff Assistant III Pharmacy Steven Haffa, RPh Senior Pharmacist Pharmacy Robert Hallisey, RPh Associate Director Partners ecare Stacey Houghton Director, Practice Support Ambulatory Care Barbara Irby Pharmacist- Resident Pharmacy Training Esther Israel, MD Physician Pediatric Medical Services Donna Jenkins, RN Patient Staff Specialist Tanya John, RPh Medication Pharmacy Pharmacist Eugene Lambert, MD Physician Department of Medicine

4 Inga Lennes, MD Instructor of Medicine, Director of Clinical Quality MGH Cancer Center, Thoracic Oncology Greg Low, RPh, PhD Program Director MGPO Performance Analysis and Improvement Denise Lozowski, RN, Quality Nurse Coordinator MGHfC MSN, CPPS Patricia McCarthy, PA Director- Medication Education,, Approval, and Compliance Karen Miguel, RN, MS, Patient Officer Radiology, Imaging CPPS Erasmo Mitrano, RPh Elizabeth Mort, MD Senior Director- Controlled Substance Compliance and Surveillance Primary Care Physician Senior Vice President for Quality and Nurse Director Office Pharmacy Department of Medicine Anti-Coagulation Walter Moulaison, RN, MSN, NE-BC Management Services Lynn Oertel, RN, MSN, NP- Nursing Practice Specialist Anti-Coagulation C, CACP Management Services Indira Padubidri Senior Project Specialist Lois Parker, RPh Pediatric Pharmacist Bigelow 6 PICU Firdosh Pathan Study Pharmacist Pharmacy Alice Peck, RN Nurse Coordinator Practice Support Prabashni Reddy Director Center for Drug Policy Eric Rosenberg, MD Director Clinical Pathology and Microbiology Laboratories Karen Ryle, RPh Associate Chief Pharmacy Operations Elizabeth Schneider Director Treadwell Library Claire Seguin, RN Senior Director Quality Office of Compliance Compliance Tammy Simeonidis Manager Pharmacy Budgets and Analytics Colleen Snydeman, RN,PhD, NE-BC Director Patient Care Services Office of Quality and Erin Stack, RPh Manager Out-Patient Pharmacy Nina Tolkoff-Rubin, MD Physician Department of Medicine Brian Verlizzo, PharmD Manager Oncology Satellite Pharmacy Alex Weatherall Administrative Director Pharmacy Jeffrey Weilburg, MD Physician Psychiatry Kevin Whitney, RN Associate Chief Nurse Surgery, Orthopedic, Neuroscience

5 Douglas Wright, MD Clinician Educator Department of Medicine Kevin Wurl Senior Pharmacist Pharmacy Participants: MESAC Safe Administration Sub-Committee Pump Team Name/Credential Title Department/Unit Jennifer Albert, RN, CCRN- Chair Clinical Nurse Ellison 4 SICU Jacqueline Collins, RN, Clinical Nurse Specialist Ellison 16, Medical Unit MSN, ACNS-BC Cynthia Finn, RN Clinical Nurse Blake 8 Cardiac SICU Patricia McCarthy, PA Director- Medication Education,, Approval, and Compliance Dawn McLaughlin, RN Clinical Nurse Bigelow 6 PICU Elisabeth Mitchell, RPh Pharmacist MGH Pharmacy Ketaki Muthal Clinical Engineer Biomedical Engineering Patricia Anglin Regal, RN Program Manager Biomedical Engineering Nathaniel Sims, MD Assistant Professor Anesthesia, Critical Care, and Pain Medicine Lisa St. Arnaud, RPh Senior Pharmacist Pharmacy Information Services Michelle Stuler, RN, MSN Informatics Project Nursing Informatics Manager Kristen Tuiskula, RPh Medication MGH Pharmacy Pharmacist Rhonda Valenti, Administrative Coordinator Anesthesia, Critical Care, and Pain Medicine Lisa Watt, MSN, PPCNP Nurse Practitioner Anesthesia, Critical Care, and Pain Medicine Outcomes: Albert s leadership, observations, and subsequent action taken, as a result of her membership on, and work with, MESAC and the Safe Administration Sub-Committee Pump Team, positioned her to address her findings and achieve the goal of reducing the rate of upper soft limit overrides for nicardipine. In the post-intervention period, the rate of upper soft limit overrides went from a range of 136 to 427 per 100 infusions to a range of 3-33 per 100 infusions.

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