The National Inpatient Medication Chart in ICU: where are we now?

1. Helen Leach Quality Use of Medicines Program Manager Department of Health The National Inpatient Medication Chart in ICU: where are we now?

2. Background • In a joint communique (April 2004) all Australian Health Ministers endorsed the use of a common chart in all hospitals • In February 2007 the NIMC was implemented across Victoria • The implementation of the NIMC was mandatory for general medical and surgical patients. Uptake into specialised patient populations, such as intensive care has been voluntary and to varying extents.

3. Overview • the extent to which the NIMC is being used across the 24 Victorian ICUs • the perceived benefits and risks • interest in the development of a standardised chart and how this might be modified from the NIMC

4. Methodology • questionnaire involving 12 open and closed questions (on-line and by phone) (Selectsurvey ASP) • circulated electronically to directors of ICU and the directors of pharmacy Limitations: • variation in methodology • qualitative • bias in distribution • Acknowledgements: • Brett ironmonger, pharmacists and nurses piloted the questionnaire, departmental colleagues

5. Results

6. Results Number of health services using the NIMC in their ICU • 18 yes • 3 no Size of the Intensive Care Units • between 3 and 32 beds (mixed)

7. Map of Victorian intensive care units (Public and Private)

8. Map of Regional Victorian intensive care units

9. Modifications from NIMC format • 3 of 18 health services using the NIMC reported that their chart had been modified: • VTE section included • increased capacity for once only medications • cross referenced to subcutaneous insulin chart • separate infusion chart • different drug administration times • entitled ‘ICU orders for Treatment Chart’ and colour identifier

10. Perceived benefits (29/41 respondents) • standardisation (Dr, N, P) • reduces risk of errors on admission and discharge (Dr, N, P) • familiarity reduced need for relearning (Dr, N, P) • ease of transition to wards (Dr, N, P) • set times of administration (N) • doctors prescribe the doses (N) • best chart seen (N) • evidence based (N) • everything works well (N) • once only and telephone orders work well (N) • duration works well for ICU (one week) (N) • Easy to use. Good instructions. Good communication. (Dr)

11. Perceived disadvantages (27/41 respondents) • multiple charts due to increased number of drugs and changes (Dr, N, P) • no provision for infusions (Dr, N, P) • large number of prn doses are difficult to accommodate (P) • insufficient space for once only drugs (Dr) • variable drug dosing (Dr) • no sliding scale insulin prn doses (N) • not user friendly for 24 hour clock (N) • boxes are too small (P) • times inappropriate (N, P) • prefer that nurses chart times (N, P) • ICU meds may continue inappropriately on discharge (P) • sometimes needed for >7 days. There should be 4 drugs only with increased room for administration (P) • nil (Dr, N, P)

12. What are the perceived barriers to implementing the NIMC in ICU (3/41) • concerns over the legibility of copies • not enough room for pharmacist’s endorsement • the present chart allows amendments to be made without crossing out the order • all orders such as regular, prn, stat can be viewed simultaneously as chart is A3

13. What, if anything, would enable the NIMC to be used in the ICU? (3/41) • a redesign of the format • changes to be consistent with our current practice • nil

14. Yes – 78% No – 22% Would you be interested in the development of a purpose designed standardised ICU chart for use statewide? (36/41)

15. How would you like a standardised statewide ICU chart to be modified from the NIMC? (21/41) • enable single administration drug infusions to be prescribed • (eg. inotropes, heparin) (5) • include observations and pathology results • extra space for stat drugs (2) • electronic prescribing on a standardised electronic format (2) • ‘I can’t believe in 2010 we still have a paper based chart in a so called developed country!! I go remote area nursing in the Northern territory (you know crocodiles, dingoes, third world conditions) and they have an excellent electronic format based electronic system that has error reduction and clinical information combined. I strongly suggest we develop a national system based on this electronic model’

16. NIMC in ICU chart modifications continued… • ..’I believe a mapping study for medication use will be the best option. We need to observe how ICU works with regards to medication use and then we need to understand what other medication processes are in use around the globe (literature evaluation). The resultant tool can then be as evidence based as possible and as a result likely to be better accepted by ICU clinicians…’ • ‘..Can we have a paediatric NIMC for long term (>7 days). A start date for antibiotics, a dilution and administration box with administration advice. SR box not used much. Better design for attachments…’

17. NIMC in ICU chart modifications continued… • more space for multiple drugs and prn orders • the medication should go on the main ICU chart, so there aren’t too many charts to deal with. Need to review medication on patient transfer. • indication and duration of treatment for some medications incorporated • happy with the design of the current modified ICU chart • not specified

18. Where to from here? • Discuss the outcomes with: • ANZICS/ACCCN (presentation then publish) • Victorian ICUs • Department of Health • Australian Commission for Safety and Quality in Healthcare • National audit to further invx patient safety

19. Summary • Majority of ICUs use the NIMC, without modifications • Perceived benefits • Standardisation • Familiarity • Ease of transfer • Evidence based design features Perceived disadvantages • Multiple charts • Not suited for number of drugs and changes needed for ICU • Infusions prescribed separately • Design • Many interested in the development of a standardised chart for ICU

20. Questions?