TABLETS - Tablets are bagged letting Emergency treat safely

Ambulance Service

This project was entered in the Baxter 2006 NSW Health Awards, Safety of Health Care category.

 Presentation given at the 2006 NSW Health Expo by Phil Good and Katie Klarenaar.

Contact: Phill Good

Abstract

Ryde Hospital Emergency Department reported that a high number of patients who were over 75 years of age were arriving at the Emergency Department without their medications. This caused some significant problems in the timely treatment of various presenting conditions.

As the problem was not isolated to Ryde Hospital, a multi-disciplinary project team was formed to devise and implement solutions which could be implemented State-wide. The project would involve Ryde Hospital and Ryde ambulance station. 

The intervention was a clearly labelled, patient identified, self sealing plastic bag, designed to hold a large quantity of medications. 

The BP sphygmomanometer was placed inside the plastic bag which was placed within the Oxy-Viva. Both pieces of equipment are always taken to patients. 

The number of patients over 75 years of age arriving with their medications at Ryde Hospital increased significantly.

Aim

To reduce the high number of patients who were over 75 years of age who were arriving at Hospital Emergency Departments without their medications.

Background

Emergency Department staff stated that the following problems are influenced by medications not arriving with patients in this age group:

Increased length of stay for patients in the Emergency Department; increased patient cycle time; increased risk of adverse events; increased length of stay in hospital; increased bed block.

A data base was compiled prior to the commencement of the project. The numbers of instances, when patients over 75 years of age were transported by ambulance without their medications, were recorded.  Measurements indicated a high incidence of patients arriving without their medications.  The need for an intervention was confirmed.

These measurements were continued for during the Clinical Practice Improvement (CPI) project.

Method

Diagnostic methodA multi-disciplinary project team was formed to devise and implement solutions for the problem.  The team included personnel from the Ambulance Service of New South Wales, Ryde Hospital, and North Sydney and Central Coast Area Health Service.

Using the clinical practice improvement methodology a diagnostic phase was undertaken. This included

• A flow chart of the process of ambulance arrival at residence to assessment/admission in hospital (Fig.1)
• Cause and effect diagram relating to the high incidence of patients over 75 years of age arriving at hospital via ambulance transport without their medications (Fig.2)
• Pareto distribution chart of the causes why ambulance officers have not  taken the medications of patients over 75 years of age to hospital (Fig 3)

It was concluded from the diagnostic phase that an intervention should be aimed at encouraging ambulance crews to gather the medications of patients over 75 years of age while at the patients’ residences.

Planning and Implementation

It was decided to introduce into the ambulance a self sealing plastic bag to enable the crews to package the medications. The bag would be kept with the patient. 

The challenge was to have the bag used by ambulance officers when attending elderly patients who require emergency care.

While the final solution was simple it required several Plan Do Study Act (PDSA) cycles during the intervention process to ensure officers’ full compliance with the intervention.

The final solution consisted of placing the BP sphygmomanometer inside the plastic bag.  The sphygmomanometer in the bag was placed within the Oxy-Viva. Both pieces of equipment are always taken from the ambulance to patients.  Placing the bags this way ensured easy access, and minimised the task being forgotten, particularly if the patient required urgent transport. 

Intervention PDSA cycles

• Officers instructed to take medications with patients (week one)
• Equipping one ambulance with clear plastic bags (week two)
• Equipping all ambulances with clear plastic bags, with the BP cuff stored in the bag (week three)
• Instruction label included on the bags (week six)
• Data field for recording “medications taken” stamped onto the Patient Health Care Record (week ten)

Outcomes and Evaluation

Figure 4 shows the number of patients arriving with their medications at Ryde Hospital over the three month measurement period. Week one of the project indicated a high number of patients, over 75 years of age, arriving at Ryde Hospital Emergency Department without their medications. The rate of medications transported with patients, over 75 years of age, had increased during the three month measurement period. 

In the 10th, 11th and 12th weeks of the project the average number of patients who were over 75 years of age arriving with their medications at Ryde Hospital Emergency Department was 77%.  This suggested and overall improvement compared to the commencement period of the project. Actual numbers also confirm this trend. 

The Ryde Hospital's Director of Emergency Medicine also reported an increase of patients, over the age of 75 years of age, arriving by ambulance with their medications. This has assisted in the earlier understanding of a patient's medical history by the Emergency Department's clinicians.  Having a patient's medications also enables an assessment of their medication regime by the treating clinicians and pharmacy personnel.

Run charts (Figures 5 &6) show the progress of the project following each PDSA cycle. 

Future Scope

Having patients arrive with their medications will benefit clinicians and consumers at all hospital Emergency Departments across the State. The Director of the Centre for Healthcare Improvement is advising the project team on strategies for spreading and sustaining the project State wide.  This medication safety project will complement the emergency care given by clinicians to patients who arrive by ambulance. The simplicity of the intervention will assist in spreading it to all ambulance settings across the state and complement hospital patient safety initiatives.The T.A.B.L.E.T.S. project will support current and future NSW Health medication safety strategies.