2005 OPEN FORUM Abstracts
IMPLEMENTATION OF A HELIOX DELIVERY SYSTEM TO ENHANCE PATIENT SAFETY
P. Achuff, MBA, RRT-NPS, S. Ferry, RRT-NPS, CCRC. The Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND: Patient safety awareness and the desire to reduce medical errors have gained recent focus as a method to improve outcomes, reduce length of stay, increase patient satisfaction and summarily contain costs. Specialty gas therapy with helium was delivered using a blender, a 100% helium tank and a non helium-calibrated regulator and flowmeter. Accurate flow estimation required use of a factor multiplied at the bedside with setup and each subsequent change. We identified the potential for medical error with this system; a possibility existed for the patient to be inadvertently placed on sub atmospheric oxygen. A system was implemented to eliminate the possibility for this type of medical error.
METHOD: To achieve this we converted our supply of 100% helium to mixed gas at 80/20 heliox. We purchased 4 heliox-calibrated, double-stage, high-pressure regulators. Air DISS fittings were added for use during mechanical ventilation. For low-pressure applications, we purchased 6 single-stage reducing valves. An alternate vendor was used to procure heliox-calibrated Thorpe tubes. These were permanently affixed to the reducing valves. Three-in-one masks were also purchased for this application. A setup to deliver aerosolized medication via Aeronebâ with heliox was also designed and implemented.
RESULTS: Each of 123 staff members was inserviced individually or in groups of 2-3 with return demonstration. Complete set-ups were placed in areas with the greatest likelihood of use. Clinicians reported the new system was faster and less complex to implement. Our previous experience with heliox therapy occurred primarily in the Pediatric Intensive Care Unit. Emergency Department usage had been reserved for extreme cases. The new dedicated system expanded our use of heliox in the Emergency Department and all other intensive care areas.
CONCLUSION: Conversion to a new heliox delivery system resulted in more rapid and frequent use of the system. An important patient safety goal was achieved by removing the possibility that patients could receive therapy with 100% helium.