Reducing Insulin Related Errors in Patients Treated for Hyperkalemia

Transcription

1 Reducing Insulin Related Errors in Patients Treated for Hyperkalemia Tan Tock Seng Hospital is an acute care general hospital with a 1,200 bed capacity The hospital addressed the problem of insulinrelated errors in patients treated for hyperkalemia using the Clinical Process Improvement Project (CPIP) methodology We wish to share their innovative solution of using a HIGH-K + pack to deal with this problem

2 Mission Statement All cases of hyperkalemia (serum K + > 6mmol/L) should have appropriate* Treatment Monitoring instituted within six hours of notification of hyperkalemia Time frame for implementation of project: Within 6 months

3 Appropriate Treatment To be started within an hour of hyperkalemia notification Correct indication (rule out pseudo-hyperkalemia) ECG and baseline capillary blood glucose(cbg) taken Stop all medications causing hyperkalemia IV Calcium Gluconate (ECG changes + Serum K + > 6.5mmol/L) IV Insulin 5-10 units + IV Dextrose Resonium IV Frusemide, if indicated

4 Appropriate Monitoring To be started within an hour of hyperkalemia notification Need for Telemetry or High Dependency stay (Serum K + >7 + ECG changes + muscle weakness + rising K + levels/other medical indication), Baseline CBG Hourly CBG for 6 hours after IV Insulin bolus Repeat ECG within 1 hour if ECG changes Repeat K + in 2 hours if ECG changes Repeat ECG in 4-6 hours if ECG normal Repeat K + in 4-6 hours if ECG normal Maintenance IV Dextrose infusion started if indicated

5 Team Members Team Leader Dr Julie George, Consultant, General Medicine Expert advisors Dr Alvin Tan, Consultant, Endocrinology Dr Jackie Tan, Head of Department, General Medicine Team Members Dr Aisah F, Medical Officer Dr Joel Lim, Resident, Dr Goh W Y, Resident, Sr Rusvinder Kaur, Nurse Clinician Ms Lim Chee Yuen, Pharmacist Ms Irene, SN, Ms Nor, SN

6 Evidence for Problem Worth Solving Sentinel Events Case 1 77-year-old Chinese male with history of hypertension, hyperlipidemia, Ischemic Heart Disease(IHD), peptic ulcer disease and renal impairment was admitted, via Emergency Department, with complaints of shortness of breath and bilateral lower limb weakness Patient was assessed as having an acute chronic renal failure and worsening IHD He was prescribed IV insulin 10 units in 40 ml Dextrose 50% solution House Officer (HO) inadvertently administered 100 units of insulin in 20 ml Dextrose 50% solution Patient was found unresponsive and glucometer showed patient was hypoglycemic He subsequently developed aspiration pneumonia secondary to coma and died

7 Evidence for Problem Worth Solving Sentinel Events.Case 2 House Officer administered IV insulin to patient as part of the management for hyperkalemia 60 units of insulin rather than the intended 6 units was administered as he assumed that 1unit of Insulin was equivalent to 1 large marking (5 small markings) on the insulin syringe

8 Evidence for Problem Worth Solving Sentinel Events.Case 3 Patient admitted for gastroenteritis associated with hyperkalemia He was prescribed 10 units of Insulin but the House Officer used a normal syringe and administered 8 mls on Insulin (equivalent to 800 units!) instead Patient developed hypoglycemia and was transferred to ICU but subsequently recovered

9 Evidence for Problem Worth Solving Sentinel Events.Case 4 Patient was admitted for treatment of hyperkalemia 8 units of Insulin were ordered House Officer drew the insulin into a 3ml syringe and administered entire volume of 3 ml to the patient intravenously Patient received 300 units instead of 8 units of Insulin!! She had 5 episodes of hypoglycemia which was treated with IV 50% Fortunately she recovered

10 Why Do Insulin-Related Errors Occur? Errors in Insulin Dosage Use of regular syringe to administer insulin Unfamiliarity with unit markings on insulin syringe Failure to monitor glucose levels following administration of insulin

11 Baseline data Baseline data of medical patients admitted in Nov 2010 and Jan 2011 for hyperkalemia: Total no of cases requiring insulin to correct hyperkalemia: 28 cases % of cases that received appropriate treatment: 78% % of cases that were monitored for hypoglycemia: 7%

12 Reasons for Inadequate Treatment & Monitoring of Patients with Hyperkalemia Protocol No existing protocol on treatment and monitoring of patients with hyperkalemia Training and Orientation No formal training and orientation for junior doctors on management of hyperkalemia Knowledge deficit Junior doctors were not familiar with insulin syringes and markings on insulin syringes

13 Interventions CAUSE INTERVENTIONS DATE OF IMPLEMENTATION No Protocol for Hyperkalemia Management Flow chart on acute management and monitoring of patients with hyperkalemia developed and placed in HIGH K + pack. Use of a stamp to assist nurses in documentation and monitoring needs of patients on treatment for hyperkalemia. 22 nd March rd May 2011 Lack of Training and Orientation Knowledge Deficit about Insulin Syringes Briefing for all Doctors and Nurses on Protocol for hyperkalemia management Training for all Doctors on use of Insulin syringes High K + pack Regular Insulin with tag to remind users to use insulin syringe. High K + pack stocked with insulin syringe. Regular Insulin with picture to show how dose should be drawn. 1 st March nd March 2011

14 Hyperkalemia Pack Hyperkalemia protocol Table of content Alcohol swabs Actrapid vial (tagged) Monitoring stamp Insulin syringes

15 Each Actrapid vial tagged

16 New Protocol for Treatment and Monitoring of Patients with Hyperkalemia New Protocol for treatment and management of hyperkalaemia S.K> 6mmol/L Hyperkaleamia Exclude pseudohyperkalaemia E.g. Hemolysis Repeat S. K Treatment Monitoring ECG + */ S.K >6.5 High risk patients: Acute renal failure/ ESRF on dialysis/ Coronary Artery Disease/ Acute Myocardial Injury 1.IV Calcium Gluconate 10 ml of 10% over 2-3 minutes ( slow infusion over 20 mins in 100mls of 5%Dextrose in patients on digoxin) Telemetry/bedside cardiac monitor/ hourly parameters( based on availability) or High Dependency monitoring if patient is unstable ECG, HC (Capillary blood ECG n/ S.K <6.5 glucose) 2.IV Insulin Regular 5-10 units + IV Dextrose 50% 40 mls bolus (Dextrose could be avoided if baseline HC>18mmol/L) Consider maintenance IV dextrose infusion* (if baseline HC <6 /NBM /Poor oral intake/ previous episodes of hypoglycemia*) 3.Resonium (PO gm or PR 30 gm) 4.Stop all IV/oral medications causing hyperkalaemia* 5.HC hourly for 6 hours Hourly parameters *Refer to details in medicine bulletin board Copyright TTSH, 2011 Repeat ECG in 10 mins to check for ECG resolution and at 30min-1 hour in patients who are not on telemetry Repeat dose of IV Calcium gluconate if ECG changes are persistent Telemetry/High dependency needed Repeat S.K+in 2 hours Repeat S.K+ and ECG in 4-6 hours Persistent hyperkalaemia 1.Repeat steps Consider IV Lasix ( with residual renal function) /Ventolin nebulisation* /dialysis*

17 Monitoring Stamp for Patients with Hyperkalemia Date: Time: Monitoring Stamp: To be signed by doctor managing the patient Telemetry or HD or hourly monitoring of vital signs Baseline CBG before IV Insulin bolus Hourly CBG for 6 hours after IV insulin bolus If ECG changes present: o Repeat ECG in 1 hour o Repeat K+ in 2 hours If ECG normal: o Repeat ECG in 4-6 hours o Repeat K+ in 4-6 hours Tick as appropriate Maintenance drip as indicated IV 5%Dextrose or IV Dextrose-Saline

18 Outcome Measures Treatment & Monitoring of Patients with Hyperkalemia Education Protocol, High K pack Monitoring stamp, education Reinforcement Mean: Men: % Compliance Nov-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun11 Jul11 Aug11 Treatment Monitoring

19 Blood Glucose Monitoring Monitoring data Nov 2010 N=9 Jan 2011 N=19 Feb 2011 N=4 March 2011 N=8 April 2011 N=15 May 2011 N=10 June 2011 N=7 July 2011 N=14 Aug 2011 N=15 Blood glucose monitoring Incidence of Hypoglycemia (overall) (CBG < 4mmol/L) 33% 21% 0% 75% 60% 70% 85% 92% 87% 11% 4% 0% 0% 0% 30% 14% 7% 20%

20 Lessons Learned All patients on insulin are at-risk for hypoglycemia because of either errors in insulin dosage or the treatment per se All patients on insulin MUST be monitored for hypoglycemia Team was able to develop an innovative solution by working closely with people on the ground the House Officers and Nurses

21 Thank You!