Delays In Administration Of Medication Research Articles

Improving Communication From Hospital to Skilled Nursing Facility Through Standardized Hand-Off: A Quality Improvement Project

Background: Inadequate hand-off communication from hospital to skilled nursing facility (SNF) hinders SNF nurses’ ability to prepare for specific patient needs, including prescriptions for critical medications, such as controlled medications and intravenous (IV) antibiotics, resulting in delayed medication administration. This project aims to improve hand-off communication from hospital to SNF by utilizing a standardized hand-off tool. This project was conducted in an inpatient, 50-bed, post-hospital skilled nursing care unit of a local SNF. The participants included all 32 staff nurses employed by the SNF. Methods: Lewin’s change management theory (CMT) guided this quality improvement (QI) project. Baseline assessment included a one-month chart review of 76 patient charts that was conducted to assess the disparities related to ineffective hand-off and medication delays in the SNF before intervention. The wait time for the availability of prescriptions for controlled medications and IV antibiotics, and delays in medication administration were assessed. Intervention: Multiple randomly selected hospital-to-SNF hand-offs were observed. Semistructured interviews with all staff nurses were conducted using open-ended questions about hand-off structure and process matters. Data gathered from observation and interviews were used to create the standardized hand-off tool used in this project. In-service training on hand-off tool utilization for SNF nurses was conducted. Champions for each shift were cultivated to assist with project implementation. Results: After six weeks of implementation, a chart review of 101 patient charts was conducted to evaluate the effects of the hand-off tool on the wait time on the availability of prescriptions for controlled medications and IV antibiotics, and medication administration. The wait time of prescriptions availability during the hospital-to-SNF transition was decreased by 79% for controlled medications, with an associated 52.9% reduction in late administration, and decreased by 94% for IV antibiotics, with a 77.8% reduction in late administration. Conclusion: The use of standardized hand-off resulted in improved communication during the hospital-to-SNF hand-off and significantly decreased the wait time for the availability of prescriptions for controlled medications and IV antibiotics. Integrating standardized hand-off into the SNF policies can help sustain improved communication, medication management, and patient transition from hospital to SNF.

Pharmacist-led program to improve transitions from acute care to skilled nursing facility care.

A pharmacist-led process to improve medication management in transitions from acute care to skilled nursing facility (SNF) care is described. The process of transitioning patients from an acute care facility to a SNF involves multiple steps, with the potential for delays in medication administration. As part of a health system's effort to evaluate barriers to timely first-dose administration after hospital-to-SNF transfers, a multidisciplinary team was tasked with defining the frequency of missed doses of high-risk medications and identifying reasons for medication administration delays. A retrospective review was conducted to evaluate medication orders for patients discharged from a community hospital and admitted to a SNF from January through June 2017 (the baseline period). This review found that 60% of first doses of high-risk medications were given after the scheduled administration time. One major barrier identified was a delay in entering medication orders in the SNF electronic medical record after SNF admission. It was also observed that 30-day readmission rates for transferred patients exceeded established readmission rate targets. To address identified process barriers, a pharmacist-led pilot program was developed. The program focused on process improvements at the same 2 hospitals and SNF sites during the period of March through May 2018. The pharmacist reviewed, reconciled, and entered medication orders prior to patient arrivals to the SNF. After pharmacist implementation, order entry delays were eliminated, and the mean delay from medication due time to administration was decreased by 68% relative to baseline data. The discharge summaries of 51% of transferred patients were found to contain medication errors, most of which were clarified and resolved prior to SNF admission. It was observed that the 30-day all-cause readmission rate after SNF transfers during the pilot program was 10.4% lower than during the same timeframe of the previous year. By implementing a pharmacist-led process for medication management in transitions from acute care to SNF care, major barriers such as delayed medication administration and medication order entry were reduced. In addition, discharge medication errors were addressed and resolved prior to patients' admission to the SNF.

Exploring Inpatient Medication Patterns

Exploratory study to examine inpatient medication administration patterns. Data from multiple sources were utilized for this study. The outcome was time difference between medication schedule and administration. A 3-level hierarchical linear regression approach, both unadjusted and adjusted, was considered for this study where medication administration events are nested within patients nested within nurses or units. Intraclass correlation coefficients (ICCs) were calculated and compared. On average, medications were delayed by 12 (SD, 48.8) minutes. From the full model, patient ICCs decreased when "unit" replaced "nurse" as the 3rd level (0.541 vs 0.444). Patients who spoke Spanish had a significant 2.3- to 4.2-minute delay in medication administration. Certified nurses significantly give medications earlier compared with noncertified nurses by 1.6 minutes. Optimal medication administration is a multifactorial concern with nurses playing a role. Nursing leaders should also consider patient demographics and unit conditions, such as culture, for medication administration optimization.

Evaluation of a Practice Improvement Protocol for Patient Transfer From the Emergency Department to the Surgical Intensive Care Unit After a Level I Trauma Activation

BackgroundED boarding is a major issue in many hospitals. ED boarding occurs when there is insufficient hospital capacity to supply inpatient beds for admitted patients. ED boarding is not only a problem because of increased wait times for patients but also because it results in delays in administration of medication, higher rates of complications, and increased mortality. MethodsIn an attempt to improve patient flow and reduce time spent in the emergency department for patients requiring admission to the surgical intensive care unit (SICU), the emergency department, trauma service, and SICU collaborated on a guideline. The protocol developed focused on level I trauma-activated patients who were admitted directly from the emergency department to the SICU. We compared the transfer times before the protocol was initiated (January 1, 2016 to December 31, 2016) with the transfer times after initiation (January 1, 2017 to December 31, 2017) using a paired Students' t-test. Other outcome variables analyzed were hospital and intensive care unit (ICU) length of stay, mortality, complication rate, ventilator days, ventilator-free days, ICU-free days, and injury severity score (ISS). ResultsThe average time to transfer for 2016 was 408.05 minutes (standard deviation 362.76) versus 142.73 minutes (standard deviation 101.90) for 2017. Emergency nurses saved 265.32 minutes per patient, totaling 8,755.56 minutes saved overall. Total amount of nursing hours saved was 146 hours. This was significant at P = 0.0015. No other variables analyzed were significant. ConclusionWe reduced the time to transfer from the emergency department to the SICU significantly by implementing a new protocol to expedite this transfer among level I trauma activations. Our protocol shows that a collaborative effort between the main emergency department and SICU can result in expedited care for injured and critically ill patients that not only increases care for the ill but also creates valuable space in a busy emergency department for better patient flow.

Use of electronic medical record templates improves quality of care for patients with infantile spasms.

Infantile spasms (IS) is a neurologic disorder of childhood where time to treatment may affect long-term outcomes. Due to the clinical complexity of IS, care can be delayed. To determine if the use of electronic medical record templates (EMRTs) improved care quality in patients treated for IS. Records of patients newly diagnosed with IS were retrospectively reviewed both before and after creation of an EMRT for the workup and treatment of IS. Quality of care measures reviewed included delays in treatment plan, medication administration, obtaining neurodiagnostic studies and discharge. The need for repeat neurodiagnostic studies was also assessed. Resident physicians were surveyed regarding template ease of use and functionality. Of 17 patients with IS, 7 received template-based care and 10 did not. Patients in the non-template group had more delays in treatment (p = 0.010), delay in medication administration (p = 0.10), delay in diagnostic studies (p = 0.01) and delay in discharge (p = 0.39). Neurodiagnostic studies needed to be repeated in 5 out of 10 patients in the non-template group and none of the 7 patients in the template group (p = 0.04). Surveyed resident physicians reported improved coordination in care, avoidance of delays in discharge and improved ability to predict side effects of treatment with template use. In a single centre, the use of protocolised EMRTs decreased treatment delays and the need for repeated invasive procedures in patients with newly diagnosed IS and was reported as easy to use by resident physicians. The use of protocolised EMRTs may improve the quality of patient care in IS and other rare diseases.

Medication Administration Delays in Non-ST Elevation Myocardial Infarction: Analysis of 1002 Patients Admitted to an Academic Medical Center.

Our goal was to assess adherence to American College of Cardiology/American Heart Association guideline-based medical therapy in patients admitted with type I non-ST elevation myocardial infarction (NSTEMI) and to determine factors associated with medication administration delay. We performed a retrospective analysis using data from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry. Baseline patient demographics, 12-lead electrocardiogram (ECG) findings, laboratory values, medications administered and the time they were administered, and in-hospital clinical outcomes were collected. Global Registry of Acute Coronary Events risk scores were calculated for all patients. We included 1002 patients admitted from the emergency department with a type I NSTEMI. A total of 802 (80%) patients received appropriate initial therapy consisting of therapeutic anticoagulation with heparin and dual antiplatelet therapy. Of the 200 (20%) patients who did not receive therapy, documentation in the chart regarding possible contraindications for administration of the medications was missing in up to half. Female sex, older age, a normal initial ECG, and prolonged time spent in the emergency department were predictors of significant delay in receiving guideline-based medications, while an elevated initial troponin was a predictor of faster medication administration. Global Registry of Acute Coronary Events risk scores had no association with the timing of medication administration. In conclusion, 20% of NSTEMI patients did not receive American College of Cardiology/American Heart Association guideline-based medical therapy. Delay in medication administration was significant for women, older individuals, and patients who did not have ischemic findings on the initial ECG.

The impact of critically ill children on paediatric ED medication timeliness

ObjectivesThe presence of critically ill patients may impact care for other ED patients. We sought to evaluate whether the presence of a critically ill child was associated with the time...

Scheduling Strategy Using Poisson Probability to Ensure 24/7 Scheduling Coverage for Emergency Nurses Caring for Patients that Have Been Sexually Assaulted

BackgroundSexual assault patients disproportionately experience gaps in health care delivery including delays in referrals, delays in medication administration, and extended lengths of stay in emergency departments. Victims of sexual assault have unique health care needs that require nurses to have extensive knowledge and skills to adequately address them. Training nurses with simulation is one approach to enhancing knowledge and skills. However, with a large number of nurses a burden is created whereby nurses have difficulty maintaining clinical competencies due to the decreased opportunity to gain actual hands‐on experience.PurposeThe purpose is to determine a reliable method for calculating an accurate number of nurses to select for simulation training so that one of the specially trained nurses will most likely be working in the emergency department on any given shift.Research QuestionIs there a reliable method to calculate the number of nurses to train with simulation so that there will be one trained nurse working at all times in the emergency department.MethodsUsing Poisson probability distribution the number of nurses selected for simulation training was calculated by reviewing a 6‐month period of emergency room nurses schedules. A schedule pattern was selected that achieved 24/7 coverage in 8am to 8pm and 8pm to 8am shifts. Nurses working at least six 12‐hour shifts in a 4‐week period were selected for analysis.ResultsTraining 6 nurses working 8am to 8pm results in a 0.143 probability that a nurse would not be working, and training 15 nurses working a shift of 8am to 8pm resulted in a 0.006 probability that one of the nurses would not be working on a given day. Training 6 nurses working 8am to 8pm results in a 0.113 probability that a nurse would not be working, and training 15 nurses results in 0.002 probability that one of the nurses would not be working on a given day.Conclusions and ImplicationsPoisson probability distribution is a reliable method to determine a number of nurses to train for simulation in order to increase the likelihood that one trained nurse is working on any given shift. Additionally, using this scheduling method, Poisson can be applied specifically to other health care specialties where there are no fixed schedules, and the need to have a health care individual with specialized skills is essential.

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units

ObjectiveTo examine medication safety in two intensive care units (ICU), and to assess the complexity of medication errors and adverse drug events (ADE) in ICUs across the stages of the...

Impact of resuscitation system errors on survival from in-hospital cardiac arrest

BackgroundAn estimated 350,000–750,000 adult, in-hospital cardiac arrest (IHCA) events occur annually in the United States. The impact of resuscitation system errors on survival during IHCA resuscitation has not been evaluated. The purpose of this paper was to evaluate the impact of resuscitation system errors on survival to hospital discharge after IHCA. Methods and resultsWe evaluated subjective and objective errors in 118,387 consecutive, adult, index IHCA cases entered into the Get with the Guidelines National Registry of Cardiopulmonary Resuscitation database from January 1, 2000 through August 26, 2008. Cox regression analysis was used to determine the relationship between reported resuscitation system errors and other important clinical variables and the hazard ratio for death prior to hospital discharge. Of the 108,636 patients whose initial IHCA rhythm was recorded, resuscitation system errors were committed in 9,894/24,467 (40.4%) of those with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) and in 22,599/84,169 (26.8%) of those with non-VF/pVT. The most frequent system errors related to delay in medication administration (>5min time from event recognition to first dose of a vasoconstrictor), defibrillation, airway management, and chest compression performance errors. The presence of documented resuscitation system errors on an IHCA event was associated with decreased rates of return of spontaneous circulation, survival to 24h, and survival to hospital discharge. The relative risk of death prior to hospital discharge based on hazard ratio analysis was 9.9% (95% CI 7.8, 12.0) more likely for patients whose initial documented rhythm was non-VF/pVT when resuscitation system errors were reported compared to when no errors were reported. It was 34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT. ConclusionsThe presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target the training of first responders and code team personnel to emphasize the importance of early defibrillation, early use of vasoconstrictor medication, and compliance with ACLS protocols.

Nurse Aides’ Reports of Resident Abuse in Nursing Homes

Verbal, physical, psychological, caregiving, medication, material, and sexual abuse perpetrated by staff are examined. Information came from nurse aides included in the Pennsylvania nurse aide registry. A total of 4,451 nurse aides returned a 46-item questionnaire (response rate = 64%). A 3-month frame of reference was used, and the questionnaire asked about abuse in the prior nursing home of employment. Nurse aide responses to the verbal abuse and psychological abuse items were higher than for the other categories of abuse examined. For example, 36% of nurse aides observed argumentative behavior with residents and 28% observed intimidation. Lower figures were reported for physical abuse (6% observed pushing, grabbing, or pinching), caregiving abuse (10% observed staff to threaten to stop taking care of a resident), medication abuse (19% observed inappropriate delays in medication administration), material exploitation (10% observed taking assets), and sexual abuse (1% observed unwelcome discussion of sexual activity). These findings clearly show that some types of resident abuse by staff are reported to be a common occurrence by nurse aides. This likely influences the health outcomes, quality of life, quality of care, and the safety of residents.

Addressing delays in medication administration for patients transferred from the hospital to the nursing home: A pilot quality improvement project

Background: Patients being transferred to a nursing home (NH) after an acute hospitalization are subject to adverse effects, including medication errors, related to poor coordination of care across settings. Objective: The goal of this study was to develop, implement, and evaluate the impact of a pilot intervention to improve patient safety by reducing delays in administration and omission of medications among patients discharged from the hospital to the NH. Methods: An expedited discharge protocol was developed in collaboration with hospital physician residents, hospital discharge planners, and NH staff (administrators, directors of nursing services, and licensed nurses). The intervention included education of the involved health care professionals and implementation of the expedited protocol to ensure that medication orders were transmitted to the NH-contracted pharmacy before patients' arrival at the NH. The intervention protocol was compared with a standard discharge protocol among patients aged ≥65 years being discharged from 2 university-affiliated hospitals to a single proprietary NH. The primary outcomes were the time between arrival at the NH and administration of first dose of an ordered medication; the number of omitted medications; the proportion of patients experiencing medication omissions; and the proportion of patients with omitted medications that had a low, medium, and high potential for negative consequences. Results: The study involved 10 patients discharged from each of the 2 hospitals and transferred to the NH. Although several components of the intervention were successfully implemented, none of the medication orders were transmitted to the NH-ccontracted pharmacy before patients' arrival at the NH. All 17 patients with medications ordered to be administered in the evening had ≥1 dose of a medication omitted after their arrival at the NH. The mean (SD) delay from arrival at the NH to administration of the first dose of an ordered medication was 12.55 (7.45) hours. The mean number of doses of different medications omitted per patient was 3.4 (2.60). Sixty-seven doses of medications were omitted; 53 of these omissions involved only 1 dose of a medication. Thirty-three percent of omitted doses involved medications with the highest potential for resulting in a negative consequence. Conclusions: The intervention to improve patient safety by reducing medication delays for patients making the transition from the hospital to the NH was not successfully implemented, as medication orders were not transmitted to the NH-contracted pharmacies before patients' arrival at the NH. All patients making the transition from hospital to NH experienced a >12-hour delay in medication administration, and the mean number of missed doses of medications was >3. There is a need for further exploration of the reasons for and possible solutions to delays in medication administration during the transition to the NH, as well as of the impact of such delays on patient outcomes, including adverse drug events, emergency department visits, and rehospitalizations.