• Jessica L Hochstetler, A Jill Thompson, Natalie M Ball, Melissa C Evans, Shaun C Frame, A Lauren Haney, Amelia K Little, Jaime L O'Donnell, Bryna M Rickett, and Elizabeth H Mack.
• Department of Pharmacy, Texas Children's Hospital, Houston, TX.
• Pediatr Crit Care Me. 2018 Jun 1; 19 (6): 572-577.

ObjectivesTo determine whether implementing a guideline to bolus medications from continuous infusions in PICUs affects nursing satisfaction, patient safety, central line entries, medication utilization, or cost.DesignThis is a pre- and postimplementation quality improvement study.SettingAn 11-bed ICU and 14-bed cardiac ICU in a university-affiliated children's hospital.PatientsPatients less than 18 years old admitted to the PICU or pediatric cardiac ICU receiving a continuous infusion of dexmedetomidine, midazolam, fentanyl, morphine, vecuronium, or cisatracurium from May 2015 to May 2016, excluding November 2015 (washout period), were eligible for inclusion.InterventionsChange in practice from administering bolus doses from an automated dispensing machine to administering bolus medications from continuous infusion in PICUs.Measurements And Main ResultsTiming studies were conducted pre- and post implementation in 29 and 26 occurrences, respectively. The median time from the decision to give a bolus until it began infusing decreased by 169 seconds (p < 0.01). Nursing satisfaction increased from 19.3% pre- to 100% post implementation. Safety was assessed via barcode scanning compliance, which decreased by 1.4% for patients and 1% for medications, and smart pump limit overrides. The percentage of infusion pump bolus overrides increased as expected, with the majority (99%) of these exceeding soft maximum limits by less than two-fold. Central line entries were unaffected post implementation. To assess medication utilization, a total of 50 patients in each intervention group were selected for retrospective chart review. Daily fentanyl boluses increased from one to three (p = 0.021). However, midazolam infusion dose and fentanyl infusion duration decreased (p = 0.026 and p = 0.005, respectively). Medication utilization was otherwise unchanged post implementation (p > 0.05). Annualized cost avoidance was $124,160.ConclusionsImplementation of bolus medications from continuous infusion in PICUs significantly decreased time to begin a bolus dose and increased nursing satisfaction. The practice change also improved medication utilization without negatively impacting patient safety.

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