Staff Nurse III Boston Children's Hospital Hingham, Massachusetts, United States
Abstract:
Introduction: There is an increasing prevalence of adolescents and adults with congenital heart disease receiving medical and post-operative care in the Cardiac Intensive Care Unit (CICU). Caring for both adult and adult-sized pediatric patients necessitates standardization of medication infusions such as sedatives and anticoagulants to ensure patients do not receive an inappropriate dose. Regardless of a patient’s age or weight, the electronic health record (EHR) at Boston Children’s Hospital (BCH) defaults to pediatric weight-based dosing when ordering medication infusions. After review of weight-based infusion-safety events, a CICU interdisciplinary team identified potential risks of utilizing weight-based dosing for adults and adult-sized pediatric patients, including higher-than recommended medication dosing and increased risk for adverse events.
Objective: The purpose of this project was to establish and safely implement standard infusion guidelines for adults and adult-sized pediatric patients.
Methods: A failure mode and effects analysis (FMEA) was performed by an interdisciplinary team of clinicians, including intensivists, pharmacists, advanced practice nursing, staff nursing, and members of patient safety and quality representing multiple intensive care units across the institution. Safety event reporting data and provider input were utilized to identify drug categories posing the greatest risk to patient safety. All infusions were reviewed and grouped into categories including vasoactives, diuretics, sedatives/paralytics, antiarrhythmics, anticoagulants/hemostatics, and miscellaneous. Data from adult-based best practices were reviewed with adult intensive care physicians and pharmacists from outside institutions.
Results: Sedative, anticoagulant, and diuretic infusions were identified as medications associated with a risk of dosing errors in adults and adult-sized pediatric patients within the established order entry system. As a result, order entry for infusions in these categories were changed to a standard non-weight based starting dose when a patient’s weight is equal to or greater than 50 kilograms. Implementation occurred across the BCH EHR, infusion pump library, and online formulary. Mandatory education was provided to all disciplines involved in order entry, reconciliation, and administration. These changes have been implemented without any documented adverse events. Conversely, vasoactive infusions were identified as safe to remain with the current weight-based dosing strategy.
Conclusions: Adjusting order entry for adults and adult-sized patients receiving care in the CICU is an important intervention to lower the risk of adverse drug events and ensure appropriate medication administration. Evaluation of efficacy, safety, and adherence to adult infusion dosing guidelines is being performed through ongoing review of safety events. Next steps include evaluating electrolyte replacement for adults and adult-sized pediatric patients.
