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					Safer Use Of Intravenous Gentamicin For Neonates
Experience Of The Care Bundle
NICU – RHSC Glasgow




                           Anisa Patel
                           Clinical Pharmacist
                           Neonatal Intensive Care Unit
                           Royal Hospital for Sick Children
Alert Action points
Local Gentamicin Protocol



                 • GG&C neonatal IV monograph
Local protocol     – States initial dose and frequency of
                     administration
  Use care
   bundle

 PDSA cycle      • Attached guideline
                   – Describes monitoring requirements
Measurement
                   – Gives advice on dosing adjustments based on
                     levels
   Training
   Elements of the Bundle


  Local
                                   Coloured           Double-         Dose within
 protocol    24-hour clock
                                     apron           checking          one hour
             •24-hour clock    •Interruptions    •A double-        •The prescribed
 Use care     format should     during the        checking          dose of
  bundle      be used when      preparation       prompt should     gentamicin
              prescribing       and               be used during    should be
                                administration    the               given within
PDSA cycle                      of gentamicin     preparation       one hour of
             •Unused time
              slots in          should be         and               the prescribed
                                minimised by      administration    time
Measureme     prescription
                                the wearing of    of gentamicin
    nt        administration
              record should     a disposable
              be blocked out    coloured apron
              at time of        by staff to
 Training                       indicate that
              dosing to
              prevent wrong     they should
              time dosing       not be
                                disturbed
Elements of the Bundle

               24-Hour Clock
• Current kardex encourages prescribing using
  the 24 hour clock
• Midnight doses prescribed as 23:59

  Block out unused time slots on kardex

• Currently only done for 48 hourly dosing
• New kardex with specific gentamicin page?
   Elements of the Bundle

                     Coloured apron
• Purple aprons worn by nursing staff during preparation and
  administration.

                    Dose within 1 hour
• Nursing staff document on the double checking prompt if a
  dose is administered > 1hour out with the prescribed time.

• Prompt reminds staff to write on the kardex exact time of
  administration if >1hr.
Double checking prompt
    NPSA version
 Double checking prompt


• Caused most difficulties with compliance

• Opted for paper copies for audit purposes

• Completed for each dose and filed in a designated place

• Discarded after audit of compliance is completed each
  month
  Small cycles of change

                 • NPSA version of prompt introduced
Local protocol     initially

  Use care
   bundle        • Amended based on use & feedback
                   from nursing staff during gradual roll out
 PDSA cycle        ( 1 patient      1 bay        whole unit)
Measurement
                 • 5 further versions to date
   Training
                 • Fit with local practice, user friendly and
                   useful for auditing purposes
    Double checking prompt
       NICU version 1


• Instruction to document time of dose on kardex if >1hr
  out with prescribed time
• Clarified who is responsible for interpretation of results
• Added dose and frequency as per local protocol


For audit purposes
• Tick box for dose administered >1hr
• Tick box for interruptions
   Double checking prompt
      NICU version 2



• Space for patient details

• Instruction to give yes / no answers instead of just
  tick box

• Comments section
  Double checking prompt
     NICU version 3



• Date – retrospective audit

• 4 & 5 removed – ? inappropriate for nursing staff to
  have to verify interpretation of results and dose
  amendments
   Double checking prompt
      NICU version 4


• Clarification of why blood results would need action
  prior to administration of next dose

• Dose should be correct for weight at start of
  treatment

• Tick box to indicate if dose prescribed using 24 hour
  clock - audit from prompt
  Double checking prompt
   NICU current version


• Today’s date?
             Measure care bundle
              compliance daily

                 •1 patient chosen at random each day by the nurse in charge
                 • Compliance with bundle audited retrospectively using checking prompt
                 • Monthly compliance form completed each day;
Local protocol
                  Day         Date   Patient    Rx’d using    Prompt     No              Dose given    Compliant
                                     Initials   24 hr clock   used       Interruptions   within 1 hr
  Use care
   bundle         Monday                                                                               Y/N
                  Tuesday                                                                              Y/N
                  Wednesday                                                                            Y/N
 PDSA cycle



                                      No. of doses audited                               =
Measurement
                                      No. prescribed using 24 hour clock                 =
                                      No. with prompt completed                          =
                                      No. with no interruptions                          =
  Training                            No. with dose given within 1hr of Rx’d time        =
                                      No. of doses fully compliant with care bundle      =
Run Chart – Individual Elements

                                                                                                                  24hr clock format used & unused time slots blocked when prescribing
                                   RHSC NICU                                                                      No interruptions when prescribing & administration Gentamicin
                           Gentamicin Bundle Elements                                                             Double checking prompt used
                                                                                                                  Dose given <1hr of prescribed dose time

    100

     90

     80

     70
                                                                  Retrospective audit : no prompt = non-compliance re interruptions & timimg of dose
     60
%




     50

     40

     30

     20

     10

      0
                                            11




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                                                            1




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            1




                                                    1




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                                                                                                                                                         2
                      11




                                                                                                                           12
                                                                              11




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                                                                                                                                                                                                           12
                                  Apr-1




                                                                                   Oct -1




                                                                                                                                       Apr-1




                                                                                                                                                                                       Oct -1
                                                          Jul-1




                                                                                                                                                               Jul-1
          Jan-1




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                                                                                                                                                                                                          Dec-
                                                                                                             Month
                                            %




                    0
                        10
                             20
                                  30
                                       40
                                            50
                                                 60
                                                      70
                                                           80
                                                                90
                                                                     100
        Ja
           n-
              11
        Fe
           b-
              11
        M
          ar
             -1
               1
        Ap
           r-1
               1
        M
         ay
             -1
                1
        Ju
           n-
              11
         Ju
            l-1
                1
        Au
          g-
              11
        Se
           p-
              11
        O
          ct-
              11
        No
           v-
              11
        De
           c-
              11
        Ja
           n-
              12
        Fe
           b-
              12
        M
          ar
             -1
               2
        Ap
           r-1
               2
        M




Month
         ay
             -1
                2
        Ju
                                                                               NPSA's Gentamicin Bundle




           n-
              12
         Ju
            l-1
                                                                           RHSC NICU - Overall Compliance with




                2
        Au
          g-
              12
                                                                                                                 Run Chart – Overall Compliance




        Se
           p-
              12
        O
          ct-
              12
        No
           v-
              12
        De
           c-
              12
        Ja
           n-
              13
        Fe
           b-
              13
        M
          ar
             -1
               3
        Ap
           r-1
               3
        M
         ay
             -1
                3
        Ju
           n-
              13
Training


  • Training session for medical staff
    covers gentamicin.

  • Nothing formal for nursing staff yet
       Outcomes?

• Recording errors with gentamicin prescribing,
  administration & monitoring

• Recurring error = missed peaks

• Portable timers introduced to alert member of
  medical staff when the peak is due

				
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posted:9/6/2011
language:English
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