cleaning up alteplase for unblocking occluded central venous catheter (cvc) in the renal dialysis...
TRANSCRIPT
Cleaning up Alteplase for unblocking occluded central venous catheter (CVC) in the
renal dialysis unit. S Lim,
Pharmacy Department,
Armadale Health Service
Overview:
NSQHS Med Safety Std 4 (empower clinicians to use med safely)
What is our problem? AHS Alteplase policy Audit Methodology Audit Results Discussions and recommendations Lesson learnt Success of these audits
Alteplase 2 mg/ 2 mL frozen syringe
High cost drug Product of
AUSPMAN, PMH Pharmacy
What is the problem:
Audit triggered by:• Discarded syringes due to cold chain failure• Retrospective cost analysis:
Audit should provide As:• Why > use?• ?Wastage factor (expiry date, incorrect storage)• ?Adherence to policy + guidelines
Source: Query Builder RPH ($) AHS ($)
Alteplase frozen syringes (1/1/10 to 21/3/12 (2 y 2 m)
3,900 14,740
AHS Alteplase Guiding Principles:
Restore patency to occluded CVC
Up to 2 doses of Alteplase (2mg) per episode
No efficacy + safety data for > than 2 doses
Method:
Baseline audit (April 2012):
• Retrospective analysis patients given Alteplase.
• Analytical period:• April 2011 to March 2012
• Data collection using compliance tools
Post-implementation audit (April 2013):
• Analytical period: • April 2012 to March 2013
Results
Baseline Audit(Apr 11 – Mar 12)
Post-Audit(Apr 12 – Mar 13)
No. of patients (n) 6 4
No. of doses administered 31 ( $4,288) Mean = 5.2 doses/patient
(1 - 11 doses/patient)
7 ($995)Mean 1.7 doses/patient
(1 – 2 doses/patient)
No. of doses given without doc 14 (45.2%)
0 (0%)
No. of doses adm without a valid Rx
9 (29%)
0 (0%)
Indication for use 17 (54.8%) unblocking14 (45.2%) for locking
6 (85.7%) for unblocking 1 (14.3%) for locking
Renal physician consultation 1 (3.2%)
6 (85.7%)
Results:
Results from the compliance audit on the use of Alteplase for Unblocking CVC lines, Renal Dialysis Unit, AHS
0
10
20
30
40
50
60
70
80
90
doses admwith no doc in
NIMC
doses admwithout a valid
Rx
amount admunknown
Use forunblocking
CVC
Use as LOCK other Tx tried
Per
cen
tag
e %
Apr 2011 to Mar 2012
Apr 2012 to Mar 2013
Discussions/Recommendations:
• Baseline Audit:
29% without a valid Rx
45.2% no doc after use Inappropriate PRN Rx
• Allow the use for 14 doses without proper review
• Potential for “Nurse Initiated Med or NIM”
45.2% for locking CVC• ?ensure future line patency• No evidence to protect
patency
• Re-audit:Re-audit:
100% valid RX
100% documentation of use
100% RX in “Once Only Med” section of NIMC:• Ensure proper review
every episode of use• Correct + proper use of
alteplase
Lesson Learnt:
Prevent misuse of alteplase:• Use “once only” section of NIMC to Rx up to 2
doses of alteplase• Empowering Renal physician to review the
usage of alteplase every episode:• Safe + proper use of potential toxic drug• Prevent misuse (not an NIM)• $ saving
Conclusion:
Compliance to NSQHS Std 4 (med safety):4.1 Develop + implement governance
arrangement, policy, procedures and protocols
4.2 Regular comprehensive assessment to identify risks + implement system change
4.3 Authorise clinicians to prescribe + administer meds.
4.5 Undertake quality improvement activities to enhance med safety
GO FREO