Patient Safety Department of Internal Medicine Faculty of Medicine Prince of Songkla University Department of Internal Medicine Faculty of Medicine Prince.

Patient SafetyPatient Safety

Department of Internal MedicineDepartment of Internal MedicineFaculty of MedicineFaculty of Medicine

Prince of Songkla UniversityPrince of Songkla University

Quality Assurance Report: 30Quality Assurance Report: 30thth November 2007 November 2007

Department of Internal MedicineDepartment of Internal MedicinePatient Safety projectPatient Safety project

Patient Safety in Patient Safety in Critically ill patientsCritically ill patients

Prevention of self extubation Prevention of self extubation in medical ICUin medical ICU

IMPACTIMPACTPatient SafetyPatient Safety

Number of medical ICU admission and Number of medical ICU admission and intubation : 2544 - presentintubation : 2544 - present

Self extubation rate in medical ICU:Self extubation rate in medical ICU:Before interventionBefore intervention

Why is self extubation important?Why is self extubation important?

Why is self extubation important?Why is self extubation important?

How could self extubation be How could self extubation be reduced?reduced?

sedationsedation

LITERATURE REVIEWLITERATURE REVIEWPatient SafetyPatient Safety

Sedation: Current IssuesSedation: Current Issues

Over-sedatedOver-sedated• increased drug costsincreased drug costs• delayed weaning delayed weaning • increased ICU length of stayincreased ICU length of stay• increased testingincreased testing

Under-sedated• anxiety and agitation• awareness and recall• post-traumatic stress disorder• increased adverse events• increased use of paralytics

Without a means to Without a means to objectively titrate objectively titrate

the level of sedation, the level of sedation, patients may be:patients may be:

Daily interruption of sedative infusion in Daily interruption of sedative infusion in critically ill patients undergoing critically ill patients undergoing

mechanical ventilationmechanical ventilation

Kress. NEJM 2000.

Effect of nurse-implemented sedation Effect of nurse-implemented sedation protocol on the incidence of ventilator-protocol on the incidence of ventilator-

associated pneumoniaassociated pneumonia

Quenot. CCM 2007.

Effect of nurse-implemented sedation Effect of nurse-implemented sedation protocol on the incidence of ventilator-protocol on the incidence of ventilator-

associated pneumoniaassociated pneumonia

Quenot. CCM 2007.

Sedation Use RecommendationsSedation Use Recommendations

• Lorazepam is recommended for sedation of most patients via Lorazepam is recommended for sedation of most patients via intermittant IV or continuous infusion (Grade=B)intermittant IV or continuous infusion (Grade=B)

• Triglyceride levels should be monitored after two days of propofol Triglyceride levels should be monitored after two days of propofol infusion (Grade=B)infusion (Grade=B)

• Use of sedation guidelines, an algorithm Use of sedation guidelines, an algorithm or a protocol is recommended. or a protocol is recommended. (Grade=B)(Grade=B)

Jacobi J. Crit Care Med 2002; 30(1): 119-142.

Sedation protocol productionSedation protocol production

AgentsAgents MixtureMixture DosageDosage PrecautionPrecaution

Morphine and Mi dazolam (M&M)

combination (First line agent)

60Morphine + + ++++++++ m 3 0 mg + NS

+ +6 0

- loading 2 3 ml iv++++ ++++++++++ +++

- 1 2 0 /p ml hr an - 13d ml iv prn.

- prolonged effect in renal prolonged effect in renal++++++++++++++++++++++-+++ +++ ++ +++++++ ++ ++++ +++ ++ +++++++ ++ +

enal dysfunction due t enal dysfunction due t o accumulation of acti o accumulation of acti

ve metabolite of Morp ve metabolite of Morp++++++++

Morphine 6 0 6 0

mg + NSS6 0 mg + NSS6 0mlml

-continuous drip 1 -continuous drip 1 - 5 13ml/hr and - 5 13ml/hr and

mi v prn. mi v prn.

- for pain control only for pain control only- as above as above

Midazolam Midazolam 3 0 Midazolam 3 0 mg + NSS6 0 mg + NSS6 0

mlml

-continuous drip 1 -continuous drip 1 20ml/hr 20ml/hr

- only for sedation only for sedation

Fentanyl 500Fentanyl 500Fentanyl mcg + NSS5 0 mcg + NSS5 0

mlml

continuous drip 0 . continuous drip 0 . 5 5– ml/hr 5 5– ml/hr

- second line agent for pai second line agent for pai n control in renal failure n control in renal failure

patientspatients

Proprofol 20Proprofol 20Proprofol 0mg 0mg

continuous drip 1 continuous drip 1- 0150ml/hr an- 0150ml/hr an

- 1030d mg iv - 1030d mg iv..

- second line agent for se second line agent for sedationdation-+++++ +++ +++ +++++++++++++++ +++ +++ ++++++++++

de level if use longer tha de level if use longer tha 5n days 5n days- no analgesic effectatall no analgesic effectatall

ScoreScore DescriptionDescription DefinitionDefinition

77 Dangerous agita Dangerous agitationtion

Pulling at ET tube, trying to remove cathe Pulling at ET tube, trying to remove cathe ters, climbing over bedrail, striking to sta ters, climbing over bedrail, striking to sta

+++++++++ ++++ ++ ++++, +++++++++ ++++ ++ ++++,

66 Very agitatedVery agitated + +++ +++ ++++ +++++++ ++++++++ ++++++ +++ +++ +++ ++++ +++++++ ++++++++ ++++++ ++ minding of limit, require physical restrain minding of limit, require physical restrain

ts, biting ETT ts, biting ETT

55 AgitatedAgitated Anxious or mildly agitated, attempt to sit Anxious or mildly agitated, attempt to sit up, calm down to verbal instruction up, calm down to verbal instruction

44 LightLightSedationSedation(Default)(Default)

Calm and Calm and cooperative cooperative

Calm, awakening easily, follows command Calm, awakening easily, follows command

33 SedatedSedated Difficult to arouse, awake or eye open to Difficult to arouse, awake or eye open to verbal stimuli or gentle shaking but drift verbal stimuli or gentle shaking but drift

off again, follow simple command off again, follow simple command

22 Moderate Moderate sedationsedation

Very sedatedVery sedated Arouses to physical stimuli but does not c Arouses to physical stimuli but does not c ommunicate of follow commands, may m ommunicate of follow commands, may m

ove spontaneously, eye close ove spontaneously, eye close

11 Heavy Heavy sedationsedation

UnrousableUnrousable Minimal or no response to noxious stimuli, doe Minimal or no response to noxious stimuli, doe s notcommunicate or followcommands, weak s notcommunicate or followcommands, weak

cough on suction cough on suction

เริ่��มให้�ยา Bolus injection และ ให้�ยาในริ่ะดั�บต่ำ��าที่��สุ�ดัต่ำาม

guideline

ที่ดัสุอบริ่ะดั�บ Sedation ของผู้��ป่!วยที่�ก 30 นาที่� และป่ริ่�บยาข$%น 1-2 ml/hr จนไดั�ริ่ะดั�บที่��

ต่ำ�องการิ่

แพที่ย)สุ��งริ่ะดั�บ Sedation ที่��ต่ำ�องการิ่

ป่ริ่ะเม�นความริ่��สุ$กต่ำ�วที่�ก 1 ชั่��วโมง

ริ่ะดั�บ Sedation มากกว-าที่��ต่ำ�องการิ่

ริ่ะดั�บ Sedation น�อยกว-าที่��ต่ำ�องการิ่

ลดัขนาดัยาลงคริ่$�งห้น$�ง ห้ริ่.อห้ย�ดัการิ่ให้�ยา

Bolus ยา และเพ��มขนาดัยาอ�ก 1-2 ml/hr

ริ่ะดั�บ Sedation อย�-ในริ่ะดั�บที่��ต่ำ�องการิ่

OUTCOMEOUTCOMEPatient SafetyPatient Safety

Self extubation rate in medical ICUSelf extubation rate in medical ICU

interventionintervention

BenchmarkingBenchmarking

LEARNINGLEARNINGPatient SafetyPatient Safety

LearningLearning• Sedation protocol is effective to prevent self Sedation protocol is effective to prevent self

extubation in medical ICU.extubation in medical ICU.• Sedation protocol did not increase ventilator Sedation protocol did not increase ventilator

day and risk of VAP.day and risk of VAP.• The collaborate of critical care nurse and The collaborate of critical care nurse and

intensivist is the key of success.intensivist is the key of success.• The incidence of extubation could possible The incidence of extubation could possible

reach to ZERO.reach to ZERO.

• We should be increase awareness and We should be increase awareness and alertness in isolated room patients.alertness in isolated room patients.

• During period of sedation interruption, During period of sedation interruption, critical care nurse must pay more attention to critical care nurse must pay more attention to the patients in order to prevent self the patients in order to prevent self extubation.extubation.

• This protocol should be implemented in all This protocol should be implemented in all ventilator care unit.ventilator care unit.

LearningLearning

Patient Safety in cancer Patient Safety in cancer patientspatients

Oncology nurse driven Oncology nurse driven chemotherapychemotherapy

IMPACTIMPACTPatient SafetyPatient Safety

Number of cancer patients in Number of cancer patients in medicine department: 2550medicine department: 2550

Medical error in Medical error in chemotherapeutic patientschemotherapeutic patients

• Inaccurate dose and drugInaccurate dose and drug• Wrong patientsWrong patients• Leakage of chemotherapy during Leakage of chemotherapy during

injectioninjection• No medical advice postchemotherapyNo medical advice postchemotherapy

Why chemotherapy error is Why chemotherapy error is important?important?

Safety in chemotherapy injectionSafety in chemotherapy injection

Oncology Oncology nursenurse

Amended Amended injection injection

techniquetechnique

Oncology nurse: job descriptionOncology nurse: job description

• Give chemotherapy to hospitalized Give chemotherapy to hospitalized medical oncology patientsmedical oncology patients

• Give medical advice for cancer patientsGive medical advice for cancer patients• Instruction and sharing the knowledge Instruction and sharing the knowledge

of caring in cancer patient to ward of caring in cancer patient to ward nurses nurses

OUTCOMEOUTCOMEPatient SafetyPatient Safety

Number of patients : Jan - Oct 07

N

Total IPD cases 2,329

Average IPD cases/day 7.8

Total OPD cases 5,280

Average OPD cases/day 17.5

Lagging indicators

N

Inaccurate dose and drug 0

Wrong patients 0

Leakage of chemotherapy during injection 0

Medical advice postchemotherapy 100

ภาคว�ชั่าและม�ลค-าที่��ม�การิ่ยกเล�กห้ล�งเต่ำริ่�ยมยา

( – มกริ่าคม ม�ถุ�นายน 2550)

0.00

5,000.00

10,000.00

15,000.00

20,000.00

25,000.00

30,000.00

35,000.00

มู�ลค่�า 2,318.50 10,068.62 29,561.40 34,685.74 7,259.02

ENTกุ�มูารเวชศาสตร�

ศ�ลยศาสตร� ส�ต�-นร�เวช อาย�รศาสตร�

Injection techniqueInjection technique

LEARNINGLEARNINGPatient SafetyPatient Safety

• New infusion technique is safe and simple. New infusion technique is safe and simple. • Oncology nurse should be implemented in all Oncology nurse should be implemented in all

cases of chemotherapy patients.cases of chemotherapy patients.• New process may be decrease unused drug.New process may be decrease unused drug.

LearningLearning

THANK YOUTHANK YOU