Thinking Outside the Bag: Ketorolac IV Direct Administration at South Health Campus, Emergency Department

Project completed as part of the South Health Campus, Alberta Health Services Green Team Competition, 2024

Team members

• Cassandra Carrier, Quality Improvement Lead RN
• Daniela Moreira, Emergency Department Unit Manager

Setting / patient group: Emergency department 

Issue

Variations in IV administration can affect the consumables required, potentially increasing costs, carbon emissions, and time. One example is the use of mini bags, where medication is diluted in 50-100 mL of IV fluid before infusion. This process can increase nursing workload, delay medication administration, and uses more resources. In contrast, direct IV administration offers faster, more precise delivery, especially in emergency settings. To explore this, a project focusing on Ketorolac, the 4th most administered IV medication in the South Health Campus ED, was chosen due to the volume of orders and its minimal impact on pharmacy workflow. 

Intervention

Stakeholders including pharmacy, The Contract, Procurement & Supply Management (CPSM)  and clinical staff were engaged. Pharmacy adjusted the Electronic health record (EHR) order setup to specify the correct administration route. This modification empowers nurses to decide how the medication should be administered. The ED nurses were involved in daily huddles when we shared relevant updates about the project's scope, goals, and potential benefits. We collaborated with bedside nurses to obtain measurements regarding the process analysis, such as average time of medication preparation prior implementation. To foster engagement, we designed posters for frontline staff, highlighting concrete information on expected financial, environmental, and social impacts. Educators and mentor nurses were early identified as key resources to provide education, guidance and support as needed.

Outcomes

Patient and clinical outcomes: 

Patients feel their needs are being met without the need of excessive supply usage and in a more timely manner. Obstacles to mobility and movement were also reduced.

Providing ketorolac IV direct over 15 seconds may reduce the medication onset time by approximately 19 minutes. Although onset pain relief was not specifically measured. The average physician assessment to discharge time was reduced by 6% and the average medication order to medication administration time was reduced by 14% when comparing a one month pre-implementation and post-implementation period. 

Environmental and economic sustainability:

Projected annual medical supplies saving is $23,266.56 and 1,271.95 kgCO2e per year, equivalent to driving 4,911 km. These savings are attributed to reduced procurement (supply chain) and disposal of medical items, and reduced energy usage from pumps.

Procurement team revealed a 25% reduction in mini bags ordering in the ED during the post- implementation period. Site-wide ordering of the mini bags was not monitored, however, due to the EHR change occurring site-wide, it is likely that a decrease in usage of mini bags was experienced in other departments.

Social sustainability:

The elimination of an IV pole and pump was identified by patients as an action which was viewed as improving overall patient experience. 

Nurses indicated they were comfortable administering Ketorolac IV direct. The majority of nurses indicated the change in process positively impacted patient experience and decreased the nurse workload.

Key learning point

A critical factor in our success was selecting a medication with straightforward administration, which garnered strong support from bedside nurses. Notably, we observed enhanced safety in medication administration, an unexpected improvement that we are eager to share with the pharmacy team. By disseminating these findings, we aim to raise awareness and facilitate the extension of this approach to other IV medications. The significant and broad ramifications that one change can have in so many different areas is encouraging and inspiring.