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Patient engagement

How a patient perspective improved IV therapy

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An expert cystic fibrosis patient questioned the timing of his drug administration, which led him to propose a new, more effective schedule for the entire ward

Abstract

Cystic fibrosis (CF) treatment is demanding and includes courses of intravenous antibiotics (IVAB), for which many patients are admitted to hospital. Our 35-bed adult respiratory ward delivers antibiotic doses up to four times a day but time pressures meant most patients did not receive their antibiotics on time. Many adults with CF are expert patients and plan their care with the healthcare team so a patient-nurse partnership was set up to resolve this issue. This article outlines a radical service change, based on a patient’s comments, that was piloted and received positive feedback.

Citation: Magtoto M et al (2015) How a patient perspective improved IV therapy. Nursing Times; 111: 20, 16-17.

Authors: Murphy Magtoto is senior staff nurse, Vivienne Green is ward sister, Mandy Simpson is matron, Susan Madge is consultant nurse - all at Royal Brompton and Harefield Foundation Trust, London.

Introduction

Cystic fibrosis (CF) is an inherited disease with no cure, although early and aggressive therapy has led to a rise in median survival (36.6 years), and few paediatric deaths. However, improved life expectancy has led to a growing burden of treatment (Cystic Fibrosis Trust, 2014).

The disease mainly affects the pulmonary and gastrointestinal systems, although comorbidities include diabetes, liver disease, osteoporosis and arthropathies (Balfour-Lynn and Elborn, 2007). Treatment is daily, time-consuming and lifelong. As health deteriorates, requirements increase, often leading to frequent hospitalisation for intravenous antibiotic (IVAB) therapy (Conway et al, 2014; Döring et al, 2012; Cystic Fibrosis Trust, 2011). Foulis Ward at Royal Brompton and Harefield Foundation Trust in London provides care for patients with chronic respiratory conditions, primarily CF. Adults with CF have managed their disease since childhood and are true partners in their care (Madge, 2006). This can be challenging to health professionals who are not accustomed to having their care questioned, but those who embrace this way of working find it rewarding.

Patients with CF, their families and the multiprofessional team work together to maintain health and manage episodes of exacerbation. This group of expert patients are a source of innovation, as is shown by a radical change in nursing practice that originated from a disgruntled patient.

Administration of medication is an important and crucial aspect of nursing practice (Greenstein, 2009). Timing of administration is vital to achieve optimum levels of effectiveness for many drugs, particularly intravenous (IV) medication. Increasingly complex and multiple IV medication regimens require:

  • Equipment selection;
  • Medication preparation;
  • Checking;
  • Administration, which can be lengthy.

Key factors are outlined in Fig 1 (attached). Setting priorities and efficient time management are necessary to execute the care plan safely and effectively (Hall, 2011).

People with CF are regularly admitted with infective exacerbations for targeted and closely monitored pharmacological therapy, attention to nutritional status and airway clearance (Horsley, 2010; Orenstein, 2004). Key in this cocktail of treatments are the increasingly vast numbers of complex IVAB, but the speed with which infective episodes are controlled is vital to preserving lung tissue and long-term health. Adults with CF take a keen interest in their therapy, and sometimes administer their own IV when they are inpatients.

Patients with CF are frequent attenders to our ward and often discuss treatment options. One such patient, David Carter*, asked about the intervals between his IV drug doses. He noted that the interval overnight was much longer than the daytime doses and wondered whether this affected his recovery. Nursing staff explained about the number of inpatients requiring IV drugs at the same intervals and the limited numbers of nurses available to administer them. Mr Carter, a deputy headteacher, said this sounded like a timetabling issue, and offered to review the schedule.

The solution

Working on the variables (number of patients, number of IV drugs, dosing frequency, preparation, administration times and number of nurses), Mr Carter created a colour-coded timetable to reduce the variations in dosing intervals. This new schedule challenged the ward nurses to change their practice and required patients to accept IV dosing either very early in the morning or very late at night.

A series of open meetings were held on the ward over a two-week period. The challenges of IV administration were made clear and nurses, patients and relatives were asked to comment on the proposed schedule or make alternative suggestions.

The sessions were well attended by nurses and families, and inpatients contributed comments to the nurses caring for them. The CF pharmacists contacted colleagues in other specialist centres to seek advice on safe practice. The CF consultants were kept up to date with the project and were very supportive.

Points addressed at meetings included:

  • An IV-competent nurse on every shift dedicated to administration of IV medication. Concern was raised about the repetitive nature of the task leading to errors, and the increase to other nurses’ workload caused by taking a nurse out of the shift. There was also concern about changing to task-based care from the holistic care in practice;
  • Non-registered IV nurse assistant. Professional concerns and issues of governance prevent this from being implemented at this hospital trust;
  • Timing. During the meetings it was agreed that few drugs were prescribed four times a day and that twice-daily IVAB therapy did not create the same issues. As a result, the new schedule focused on IV therapy being administered three times a day;
  • Administration distribution. The ward team suggested splitting the thrice-daily delivery into three groups: early, mid and late. The patients on the ward at the time voted on the options. The schedule was trialled for three weeks (>1,000 doses) to refine the times. The most popular options were retained and grouped (Table 1, attached). Patients were given choice of which option they wanted when admitted to the ward.

Patient evaluation

The new schedule was piloted for a month with about 50 patients. Those who received IVAB three times a day were asked for feedback, which was positive, and included:

  • “Good plan, good option”;
  • “I like my IVs early, especially when I’m unwell”;
  • “Works well, even if later. Perfect choice”;
  • “Works with other plans for the day”;
  • “Good time schedule. Good times”;
  • “Good timing, especially for body-clock timing”.

Conclusion

Although partnership in care is often recommended by governments, health services and patient groups, there are few documented examples. Healthcare workers often see patients at a time of crisis and know little about their daily lives. However, in addition to becoming expert in both the clinical and management aspects of their illness, patients with lifelong conditions may also have skills from their employment or hobbies that can contribute to the organisation or delivery of care. Adults with CF are used to forming partnerships for their care management, which is an example of patients and nurses working together to overcome a treatment issue.

This initiative has not only solved a management problem but has also contributed to the cohesiveness of the ward nurse team and boosted staff confidence in responding positively to patient questions. Enthusiasm about their ability to bring about change has resulted in nurses looking at further developments including 24-hour continuous infusions and a change in handover times, both of which allow for improved delivery of care. Patients now know they can be part of a positive change on the ward and nurses understand that change does not have to be complicated or instigated by external forces.

*Not patient’s real name

Key points

  • Providing timely care on busy wards is often challenging
  • Patients can offer invaluable suggestions that will improve their care
  • Radical change in nursing practice need not be complex
  • Patient-nurse partnerships can have a positive effect on clinical practice
  • It is vital to pilot and evaluate new systems before they are introduced 
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