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Practice Change From Intermittent Medication Boluses to Bolusing From a Continuous Infusion in Pediatric Critical Care: A Quality Improvement Project

Hochstetler, Jessica, L., PharmD1; Thompson, A., Jill, PharmD, BCPPS2; Ball, Natalie, M., BSN, RN3; Evans, Melissa, C., MD4; Frame, Shaun, C., MSN, CCRN3; Haney, A., Lauren, PharmD, BCPPS2; Little, Amelia, K., MSN, RN3; O’Donnell, Jaime, L., MSN, CCRN3; Rickett, Bryna, M., MSN, CPN3; Mack, Elizabeth, H., MD, MS4

Pediatric Critical Care Medicine: June 2018 - Volume 19 - Issue 6 - p 572–577
doi: 10.1097/PCC.0000000000001549
Quality and Safety

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.

1Department of Pharmacy, Texas Children's Hospital, Houston, TX.

2Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC.

3Medical University of South Carolina, Charleston, SC.

4Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, SC.

This work was performed at the Medical University of South Carolina, Charleston, SC.

The authors have disclosed that they do not have any potential conflicts of interest.

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©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies