Propofol as a Drug of Diversion: Changing Disposal Practices to Reduce Risk

Background Propofol is a drug of diversion because of its high-volume use, lack of prescribed control mechanisms, and accessibility. As a result, intensive care unit nurses and other health care professionals are placed at unnecessary risk. Decreasing the risk of drug diversion can save lives, licenses, and livelihoods. Local Problem Objectives were to reduce the risk of drug diversion and diminish the environmental impact of medication discarded down the sink. Disposing of residual propofol into activated carbon pouches was successful and sustainable in operating rooms at the study institution. Literature findings supported this intervention because of propofol’s potential for abuse, ongoing diversion events, ease of access, poor control mechanisms, lack of standardization, excessive waste, and ecological impact. Methods The intensive care unit with the highest propofol use was selected to replicate the propofol disposal process used in the operating rooms. Activated carbon pouches and bottle cap removal tools were located in each intensive care unit room at the nurses’ workstation for ease of use. Audits of unsecured waste bins and staff surveys of institutional policy awareness, disposal processes, barriers, and concerns were completed before and after the intervention. Results Survey results determined significant concern for drug diversion risk. The pilot project displayed success: 44.1% of propofol bottles in waste bins were full before the intervention and 0% were full afterward. Conclusion Following institutional approval, this propofol disposal process was replicated in all intensive care units and the emergency department in the study institution.

An Evidence-Based Protocol for Manual Prone Positioning of Patients With ARDS

Background Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device. Review of Evidence A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment. Implementation An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation. Evaluation This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications. Sustainability Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods. Conclusions Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.

NRP Versus PALS for Infants Outside the Delivery Room: Not If, but When?

Background Both the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines can be used for infants requiring cardiopulmonary resuscitation outside the delivery room. Each set of guidelines has supporting algorithms for resuscitation; however, there are no current recommendations for transitioning older infants outside the delivery room. Objective To provide background information on the algorithms in the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines and to discuss the role that nurses and advanced practice nurses play in advancing scientific research on resuscitation. Content Covered Summaries of both sets of guidelines, differences in practices, and recommendations for practice changes will be discussed. Discussion Provider preference and unit practice determine which guidelines are used for infants outside the delivery room. Providers in pediatric intensive care units and pediatric cardiac intensive care units often use the Pediatric Advanced Life Support guidelines, whereas providers in neonatal intensive care units use the Neonatal Resuscitation Program guidelines for infants of the same age. The variation in resuscitation practices for infants outside the delivery room can negatively affect resuscitation outcomes.

Using Simulation to Improve Adherence to Get With the Guidelines Time to First Shock

Background Evidence demonstrates that shocking patients in ventricular fibrillation or pulseless ventricular tachycardia in 2 minutes or less leads to improved outcomes. At our facility in Orlando, Florida, 4 of 7 time to first shock fallouts occurred in the intensive care unit. No standardization for conducting code situations existed in the intensive care unit. Objective To develop nurse simulation education and training to standardize intensive care unit code processes and improve compliance with timely defibrillation. Methods The sample consisted of intensive care unit nurses. Interventions included online education, simulation, and a postintervention survey. Analysis was conducted using the Get With the Guidelines program as well as descriptive statistics. Interventions Online education assigned to all intensive care unit nurses included electrocardiogram recognition and code documentation. Nurses and physicians collaborated to develop a diagram to identify roles needed for successful conduct of a code situation. A code simulation video was created, reflecting these roles, and embedded in the online education. The education was graded and remediated one-on-one with nurses. Intensive care unit nurses completed structured code simulations, allowing them to practice serving as the leader. Three months after the intervention, a survey was distributed to nurses. Results The time to first shock fallouts in the intensive care unit decreased by 100%, and the facility’s fallouts decreased by 71%. The facility’s adherence to the time to first shock metric increased from 42% to 83%. In a postintervention survey, 89% of nurses reported perceived improvement in knowledge, team leadership and communication, and confidence associated with code events. Conclusions Online education and code simulation positively affected time to first shock in code situations and empowered nurses to confidently function in these situations.

Favorable Outcomes After Implementing a Nurse-Driven Sedation Protocol

Background In patients receiving mechanical ventilation, prolonged exposure to sedative and analgesic medications contributes to negative clinical outcomes. Objective To reduce exposure to sedative and analgesic medications among patients receiving mechanical ventilation by implementing a nurse-driven sedation protocol. Methods This quality improvement project followed a plan-do-study-act cycle. Nurses were educated on the protocol, and 30 patient medical records were reviewed both before and after protocol implementation. Data were extracted on intensive care unit length of stay, duration of mechanical ventilation, duration of continuous sedation, presence of delirium, pain, level of sedation, and performance and documentation of spontaneous awakening trials. Data were analyzed using descriptive statistics, the χ2 test, and calculated percent change. Results Forty-four nurses completed protocol education. The mean (SD) duration of mechanical ventilation decreased by 26% (from 5 [3.7] days to 3.7 [3.2] days), and the mean (SD) intensive care unit length of stay decreased by 27% (from 6.3 [4.3] days to 4.6 [3.7] days). The mean (SD) duration of continuous sedation decreased by 35% (from 6419 [7241] minutes to 4178 [4507] minutes). Spontaneous awakening trials documented increased by 35% (from 57% to 77%), and spontaneous awakening trials performed increased by 92% (from 40% to 77%), a statistically significant change (P = .004). Conclusion These preliminary data suggest that implementation of a nurse-driven sedation protocol resulted in favorable outcomes by decreasing duration of mechanical ventilation, intensive care unit length of stay, and duration of continuous sedation and increasing the number of spontaneous awakening trials performed.