Transcript ASBMT2013-Carelock

Improving the Reliability of
Immunosuppressant Drug Levels
Michelle Kosik, Carrie Zeh, Trista Carelock, Penny
Odem, Chrissy Boyd, & Kelly Hill Rose
February, 2013
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PROBLEM
The Colorado Blood Cancer Institute BMT Program at
Presbyterian/St. Luke’s Medical Center, a member of the Sarah
Cannon Blood Cancer Network, had 14 confirmed TAC/CSA lumen
contaminations in 2010. In March 2011, auditing revealed 5
additional contaminations. This prompted a process improvement
initiative.
The goals of the process improvement were to:
1. Improve the reliability of TAC/CSA levels and resulting dose
adjustments
2. Improve patient satisfaction with the process (lumen
contamination necessitates peripheral sampling causing
increased discomfort and risk for patients)
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DEFINITIONS
 Contaminate: Immunosuppressive agents (TAC/CSA) adhere to the inner aspect of the patient’s
central access device. If a nurse inadvertently withdraws blood from the lumen that TAC/CSA has
infused into, the resultant drug level will be higher than the actual circulating blood drug level.
 TAC/CSA: Tacrolimus and cyclosporine are immunosuppressive agents that are administered after
allogeneic transplant to reduce the activity of the patient’s immune system to lower the risk of
rejection.
 Float Pool Staff: a centralized hospital based pool of nursing staff who have been trained to work in
specialty areas.
 Contract RNs: nursing staff contracted for 13 week assignments and designated to the Blood and
Marrow Transplant Units.
 UBC: Unit Based Councils provide the opportunity for frontline nursing staff to have a voice in their
nursing practice and patient care using evidence based practice. The council is actively engaged in
creating solutions to problems in our care areas.
 RN Resource: Dedicated BMT nurse with 2 years experience who is assigned to resource/mentor
float pool or contract nursing staff unfamiliar with BMT processes and medications.
 Healthstream: internet-based education program that documents compliance with assigned
learning modules.
 Meditech: (Medical Information Technology) The healthcare information system utilized at our
facility.
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POTENTIAL CAUSES FOR INCREASED CONTAMINATED
BLOOD DRAWS
 Forty new staff hired in a 24 month period
 Census and acuity were higher than had been previously sustained
 An increased number of contract RNs (travelers) had been hired
 Float pool staff were being cross-trained to the BMT units.
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INTERVENTION
Immediate efforts focused on nursing staff re-education
 The Unit-Based Council (UBC) led this process improvement initiative
 The UBC recommended the following alerts:
–
At allogeneic patient admission, nurse to dedicate lumen for TAC/CSA infusion using
light green colored tape
–
No TAC/CSA sampling to be performed from designated lumen
–
TAC/CSA Infusion to be primary line into dedicated lumen
–
TAC/CSA infusion to be turned off for 10 minutes prior to blood sampling
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ADDITIONAL RECOMMENDATIONS
During the review process, another contamination occurred
 The UBC made additional recommendations:
–
BMT Unit Float Guidelines were reviewed and the updated TAC/CSA process
added.
–
The updated TAC/CSA process was added to traveler orientation
–
A RN resource was assigned to all new hires, float staff and travelers
–
A TAC/CSA process education poster was created and posted on the BMT units
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ANOTHER CONTAMINATION
In February, 2012, another contamination was noted. The leadership team
and the UBC convened to review and identify additional opportunities.
 A mandatory Healthstream module for nursing was developed on the topic of
immunosuppressant medications.
 It was determined that all lumens other than the one being used to obtain the blood
sample should be clamped during the blood sampling process.
 Multiple disciplines (nursing, pharmacy and informatics) collaborated to create a popup screen in Meditech that appears when immunosuppressant medications are
scanned – “Infuse via designated lumen ONLY. For help, see your charge nurse.”
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RESULTS
# of TAC/CSA Contaminated Lumens
16
14
12
10
8
Contaminates
6
4
2
0
Jan-Dec 2010 Jan-March 2011 April-Sept 2011
Feb-12
May-12
Oct-12
Nov-12
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DISCUSSION
Ongoing review continues.
 2013 Skills labs – mandatory review of TAC/CSA process
 New TAC/CSA process competency required of all BMT staff within 3 months of hire
 Added to High dose Chemotherapy Checklist- “Designate white lumen with green tape
if the patient will receive TAC/CSA.”
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