National Inpatient Medication Chart Revolution and now evolution

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					National Inpatient Medication Chart
 Revolution and now evolution ….


                 Naomi Burgess
                 Pharmacy Consultant
      Medication Safety & Pharmaceutical Reforms
                   Clinical Systems
                       SA Health
Overview
• Revolution
  – Standardised national inpatient medication chart (NIMC)

• Evolution
  – Governance
  – Additional medication charts
  – Change register process
  – Quality assured NIMC
  – Other medication safety initiatives
Revolution
Australian Health Minister’s Conference, April 2004
“To reduce the harm to patients from medication errors, by June
  2006, all public hospitals will be using a common medication
  chart.
  This means that the same chart will be used wherever a doctor
  or nurse works and wherever the patient is within a hospital.”
Revolution
Australian Council for Safety & Quality in Health Care
• Multi-disciplinary committee – content experts
• standard acute inpatient chart prototype
• Based on common errors on medication charts & proven
  strategies for prevention
• Extensive pilot and evaluation in target group
   – modification

• National implementation in public hospitals by early 2007
   – State health departments

• Supported by education and audit processes
NIMC
Version E
Challenges
•   Pilot ….national uptake ….and beyond….

•   Ongoing audit and learnings
     – Human factors
•   Different look & layout
     –   focus our eyes to ‘see’ the elements of the chart eg warfarin section, administration times
     –   PRN section
     –   location in patient folders

•   New processes
     –   4pm INR levels
     –   prescribers entering dose administration times
     –   faxing orders, use on discharge

•   Resources for implementation and training eg rural areas
     – NPS Online education tool
 Challenges
• Specific medications
   – eg IV fluids, insulins, heparin

• Application in broader settings
   – eg paediatrics, longer stay patients
   – GP managed beds, private sector

• Ongoing governance & version control
   – Council term complete
Need for change….Evolution
• Governance
   – Council to Commission transition
• National Inpatient Oversight Committee 2006
   – State health departments
   – Medical, nursing, pharmacy, public and private,
     SHPA, RCNA, paeds/adult
   – Quarterly meetings

• Version control and maintenance of NIMC
• Ancillary charts
NIMCO activities
 • Versions
    – Adopted NIMC Versions D & E (incl NCR copies)
    – Modification to warfarin dose time alignment
 • National Change Register
    – To identify potential issues and solutions
 • Jurisdictional Guidelines for Version Control of the NIMC
    – Process for submission for modifications
    – Based on evidence of need and of potential for improvement
 • Quality assurance process
    – Formal and ongoing assessment of use
    – Incorporate learnings
Long stay medication chart
• State-based charts reviewed
• National long stay chart
  recommended
   – 35.5 day chart for acute ‘long
     stay’ patients
   – Based on NIMC
   – Includes warfarin section plus
     5 regular medications plus
     prn
Paediatric medication charts
• Developed through voluntary consensus process
  involving members of the CHA Medication
  Safety/Paediatric NIMC Group
• Short & long stay versions
• Dose calculation eg mg/kg
• Double signature
• Gestational age
• No warfarin
Paediatric medication chart
Paediatric medication charts
• Endorsed by Children’s Hospital Australasia (CHA)
• Endorsed by NIMCO
• CHA & NPS working with paediatric hospitals to develop an
  educational package
• Further evaluation required
• CHA /NIMCO recommend that all Australian paediatric
  specialty hospitals adopt
• CHA recommendation that all hospitals with paediatric beds
  should utilise the Paediatric NIMC for admitted children.
Insulin and BGL
• High risk medications
• Increasing evidence inpatient glycaemic management
  important even in non-critical are environments
• Protocol driven
• Specific monitoring and documentation required
• Many requests for national standardised chart
• Queensland (SMPU) work up charts and trial
               Worked Example: Insulin Intravenous
            Infusion Order and Blood Glucose Record

Target BGL range

BGL Record Graph

BGL Reading and Infusion
Rate

Recommended starting
doses
Insulin Infusion
Rate Order
Syringe Prescription and
Administration Record

        For more forms contact Ronnie Elder or Fiona McIver (3636 9748)
                 S a fe
                    M e d ic a tio n
                        P r a c tic e
                              U n it    Developed in conjunction with the Safe Medication Practice Unit
 Prescribing on the new Insulin Subcutaneous Order & Blood Glucose Record

  Demographics, Special Instructions, BGL                                                              Supplemental / Variable Insulin
                                                                                                  • In some circumstances patients may require a SUPPLEMENTAL dose of insulin if their
 Frequency and Monitoring                                                                           condition, dietary intake or a medication is altering their insulin requirements, or if the
• Complete patient identification section. Check that the label is correct and write the            patient has recently commenced subcutaneous insulin and the optimal doses are not
  patient’s name below the label. Complete the Facility, Ward/Unit and Year                         yet determined
• Specify the Target BGL Range in the shaded box on the right hand side of the form               • If the patient is receiving ROUTINE rapid acting (e.g. Novorapid ®; Humalog ®) or short
• Write when to NOTIFY of BGL out of range in the “Special instructions” box                        acting (e.g. Actrapid ®; Humulin R ®) insulin, the same insulin type should be
Safe BGL target for most patients in general wards is 5-10 mmol/L. Certain                          prescribed as a “top up” at mealtimes in addition to the ROUTINE dose if indicated by
 situations (e.g. pregnancy) require tighter control                                                the BGL at the time
• Indicate the BGL frequency required for the patient: Standard BGL monitoring for an             • If the patient is receiving twice daily mixed insulin (e.g. Novomix 30 ®; Humilin 30/70
                                                                                                    ®), the supplemental dose at other mealtimes would normally be a rapid acting
  inpatient is “Pre meals and 2100”
• Consideration should be given to whether the patient requires more frequent BGL                   (Novorapid ®; Humalog ®) insulin, but short acting insulin (Actrapid ®; Humulin R ®) may
  monitoring (e.g. 0200 if risk of hypoglycaemia)                                                   also be used
• For patients whose BGLs are stable, less frequent monitoring can be considered if               • The initial dose should be written as a whole number only in the “Start Date” column
  treatment, diet and activity levels are not changing                                            • Doses can be updated in the “Date of change” column in the “Supplemental/
• The BGL frequency should be reviewed and updated regularly. Document changes in the               Variable” section
  “Date” column of the Monitoring and Administration Record                                       Variable Insulin:
                                                                                                  • Variable dose insulin may be prescribed, however is NOT RECOMMENDED as the
                                                                                                    sole insulin therapy. SEEK ADVICE
     Insulin Orders
• Divided into 3 sections: Routine; Supplemental/ Variable and Stat / Phone Insulin Orders
• Patients may require no insulin (BGL monitoring only), or any combination of the 3 types of
  orders in , ,                                                                                         Stat / Phone Insulin
• Cross reference all insulin orders in the Medication Chart                                       • If there is to be a single dose ordered (e.g. half usual dose before surgery), or if the
                                                                                                     MO is notified of a BGL that is out of range, a stat dose may be ordered here
                                                                                                   • If a Registered Nurse (RN) takes a phone order for ANY dose (Routine or because
                                                                                                     BGL requires notification), this is where it is documented
    Routine Insulin                                                                                  Note: A second RN or an Endorsed Enrolled Nurse (EEN) MUST READ BACK the
• Prescribe all routine insulin in this section                                                      order to the doctor to confirm and countersign the phone order
• Each dose is prescribed in a different space according to when it is to be given                 • Phone orders should be signed by the prescriber within 24 hours
      • Use the prescribing space with the appropriate Meal/ time label, e.g. “Breakfast”
      • Additional prescribing spaces without Meal/ time labels are for those patients who
          require 2 different insulin doses at the same mealtime, e.g. if Protaphane® and
          Novorapid® are both required at breakfast
• “Type of insulin” – Write the FULL TRADE NAME of the insulin to be administered (Trade
  name use is preferred in insulin prescribing to avoid confusion)
• Sign each order and print your name in full at least once per form                                             Always Review Diabetes
• Under the “Start Date” column, write the date and number of units the patient is to receive
• Note that “units” is watermarked in the column, so write the whole number only                                     Treatment Daily
• Additional columns “Date of change” can be used to update the dose of insulin if
  adjustment is required
• You do not need to rewrite the entire order unless the insulin type is to be changed
• Initial each change
• If the dose does not require adjustment, the order stays current for the duration of the form
• A new form MUST BE REWRITTEN after 6 days.
Insulin and BGL
 Outcomes
 • Not just a chart – builds in protocols
    – Issues around agreement of clinicians on optimal protocols
 • Good compliance with documentation
 • Little or no change in therapeutic outcome due to
   poor application and understanding of protocol
 National Insulin Prescribing and
 Administration Chart Committee
• Proposed to investigate and advise on potential for
  national chart
• reflect a broad range of interests and expertise related to
  the care, epidemiology and demographics of diabetes
  determine
Anticoagulation
• WA has successfully used a separate chart for
  anticoagulation
• NIMCO has received some requests to consider
  removal of warfarin from charts
   – 9% adult population on warfarin
   – Stabilised patients vs acute therapy
   – ‘real estate on chart’
• Await report on outcomes from WA
DVT prophylaxis
• NICS protocol
• Some sites have embedded
• Stickers
• Communication with NICS
• Formal proposal
• Evaluation
Electronic format
• Limitations of paper-based charts
• Platform for an electronic chart
• GPs using software eg Medical Director
• inhibiting adoption in rural settings
• ongoing focus, slow progress
Other areas
 • Aged care
 • PBS
 • Syringe drivers
 • Chemotherapy
 • Palliative care
 • +++