1. Cleaning up Alteplase for unblocking occluded central venous catheter (CVC) in the renal dialysis unit. S Lim, Pharmacy Department, Armadale Health Service

2. Overview:  NSQHS Med Safety Std 4 (empower clinicians to use med safely)  What is our problem?  AHS Alteplase policy  Audit Methodology  Audit Results  Discussions and recommendations  Lesson learnt  Success of these audits

3. Alteplase 2 mg/ 2 mL frozen syringe  High cost drug  Product of AUSPMAN, PMH Pharmacy

4. What is the problem:  Audit triggered by: Discarded syringes due to cold chain failure Retrospective cost analysis:  Audit should provide As: Why > use? ?Wastage factor (expiry date, incorrect storage) ?Adherence to policy + guidelines Source: Query Builder RPH ($)AHS ($) Alteplase frozen syringes (1/1/10 to 21/3/12 (2 y 2 m) 3,90014,740

5. AHS Alteplase Guiding Principles:  Restore patency to occluded CVC  Up to 2 doses of Alteplase (2mg) per episode  No efficacy + safety data for > than 2 doses

6. Method:  Baseline audit (April 2012): Retrospective analysis patients given Alteplase. Analytical period: April 2011 to March 2012 Data collection using compliance tools  Post-implementation audit (April 2013): Analytical period: April 2012 to March 2013

7. Results Baseline Audit (Apr 11 – Mar 12) Post-Audit (Apr 12 – Mar 13) No. of patients (n)64 No. of doses administered31 ( $4,288) Mean = 5.2 doses/patient (1 - 11 doses/patient) 7 ($995) Mean 1.7 doses/patient (1 – 2 doses/patient) No. of doses given without doc14 (45.2%) 0 (0%) No. of doses adm without a valid R x 9 (29%) 0 (0%) Indication for use17 (54.8%) unblocking 14 (45.2%) for locking 6 (85.7%) for unblocking 1 (14.3%) for locking Renal physician consultation1 (3.2%) 6 (85.7%)

8. Results:

9. Discussions/Recommendations: Baseline Audit:  29% without a valid R x  45.2% no doc after use  Inappropriate PRN R x Allow the use for 14 doses without proper review Potential for “Nurse Initiated Med or NIM”  45.2% for locking CVC ?ensure future line patency No evidence to protect patency Re-audit:Re-audit:  100% valid R X  100% documentation of use  100% R X in “Once Only Med” section of NIMC: Ensure proper review every episode of use Correct + proper use of alteplase

10. Lesson Learnt:  Prevent misuse of alteplase: Use “once only” section of NIMC to R x up to 2 doses of alteplase Empowering Renal physician to review the usage of alteplase every episode: Safe + proper use of potential toxic drug Prevent misuse (not an NIM) $ saving

11. Conclusion: Compliance to NSQHS Std 4 (med safety): 4.1 Develop + implement governance arrangement, policy, procedures and protocols 4.2 Regular comprehensive assessment to identify risks + implement system change 4.3 Authorise clinicians to prescribe + administer meds. 4.5 Undertake quality improvement activities to enhance med safety

12. GO FREO