Background:
The cardiac Critical Care Unit at the Liverpool Heart and Chest Hospital is a busy 30 bedded unit with high medication use. The use of IV medication and subsequently IV giving sets on the unit, is high.
Medications were often prescribed to be given via either the IV or oral route. Electronic prescribing records were used where a nurse selected the administration route of a medication via a drop-down box. There were no guidelines to help nurses choose the most appropriate route of administration and therefore decided by individual nurses. As a result, practice amongst nursing staff varied.
Medication given via the oral route, when clinically appropriate, is the preferred route due to reduced costs, reduced infection risks to patients, improved patient experience and reduced staff time pressures. Medications given orally have a lower carbon footprint than those given IV, due to reduced packaging, transport costs, and they do not require the use of giving sets and other equipment (BMJ, 2023). However, it was understood that staff on the unit used the IV route in the majority of cases. Misconceptions regarding the efficacy of IV paracetamol (it being stronger than the oral equivalent) existed amongst the clinical staff.
For medications that are required to be given via IV, the recommended hanging time for giving sets is between 72-96 hours, medication dependent. On the unit, lines were not routinely labelled to outline expiry dates, therefore line-change practice varied from one practitioner to another.
Specific Aims:
To
Encourage the administration of potassium and paracetamol using the enteral route in place of the intra-venous route, when clinically appropriate (titled The 2 Ps project).
Standardise the hanging times of IV giving sets to 72 hours
Methods:
The Critical Care Matron and a team of nurses obtained baseline data by reviewing 40 patient records. Immediate post-op patients were omitted from the study. Three drugs were looked at - paracetamol, potassium and phosphates. Phosphates were rarely used - therefore excluded from the study. Data confirmed a significant preference for IV route over oral route in the Unit - 70% of patients received IV paracetamol compared to just 30% via the oral route. IV potassium was also favoured over oral (sando K)
The team devised a questionnaire. Staff were asked:
Their role and experience
Their perceptions of IV medication use, when oral alternatives are available
How confident they felt in switching from IV to oral route
Their understanding of patient outcomes and patient experience regarding the impact of reducing IV medications
A total of 34 responses were received. Most staff felt that reducing IV medication use would not negatively impact patient outcomes but may increase infection risks associated with unnecessary discontinuation of lines. Many felt this could be mitigated against if the lines were left attached.
There was a perception amongst staff that IV paracetamol was stronger than an oral dose. The team consulted with the pain team who advised of the poor evidence base for IV paracetamol versus oral, and recommended IV for pain reasons for 24hrs only before undertaking a review. They were in support of the project’s proposals of replacing it with oral doses in critical care.
Questionnaire responses showed that almost all staff felt confident to undertake the switch independently from the IV to oral route.
Aim 2: Standardise the hanging times of IV giving sets to 72 hours
Staff were asked about their current practices related to giving set changes when using IV Paracetamol, potassium.
There was a lack of awareness about the guidelines for the hanging times of paracetamol and potassium which led to inconsistencies of labelling lines and differing practices varying from 72hourly to once per shift.
Implementing change:
The team led by example and supported their peers in adopting sustainable practices. Micro-teaching sessions were carried out across the Critical Care Unit by the champions - brief, focused sessions introducing the aims of the initiative, the proposed changes, and the environmental and clinical rationale behind each change.
Pharmacy teams supported the project -ensuring switches were clinically appropriate, safe and effective. They provided costing, IV labels and supported with bedside teachings.
A Poster was designed to prompt staff to consider the changes and remind them of the teachings.
Results:
Patient outcomes:
IV medications continue to be used when clinically indicated.
Switching from IV to oral medications in critical care settings can significantly enhance patient comfort, independence, mobility and dignity by removing the need for infusion lines or syringe drivers. Trips to the ambulance bay were popular with long-term patients (family members bring along patients’ pets - bringing boosts to patient morale and reduction in anxiety. Improved mobility supports earlier and more effective rehabilitation, which can lead to quicker, safer discharges and reduced length of stay in critical care.
Minimising line manipulation through our second change to extend the life of hanging times may improve patient comfort and reduce risks such as phlebitis, fluid overload and medication errors. Research shows there is no increase in infection risk associated with longer hanging times.
Environmental sustainability:
Assuming that a third of IV bags could be switched to tablets, savings of 97.3 kgCO2efor Potassium and 128.6 kgCO2e per month could be achieved. Extrapolated to a year, switching from IV to oral would lead to GHG emissions savings of 1,167 kgCO2e for Potassium and 1,543 kgCO2e for Paracetamol. This is a total saving of 2,710 kgCO2e, equivalent to driving 7,973 miles in an average car.
Unfortunately data was unavailable regarding the line changes part of the project therefore excluded in the final reporting to date. The team plan to continue the project and collect data in the near future.
Economic Sustainability
Assuming that a third of IV bags could be switched to tablets, we were able to extrapolate the following costings.
Paracetamol:
IV cost: £1,074.97/month
Oral cost (2 tablets per dose): £741.43/month
Monthly savings: £333.53
Potassium:
IV cost: £11,162.30/month
Oral cost (4 tablets per dose): £7,679.45/month
Monthly savings: £3,482.85
Additional savings from reduced use of giving sets: £1,196.15/month. Total projected annual savings: £56,148.
Social sustainability
10 patients gave responses:
6 patients preferred oral medication
2 patients said either
4 patients preferred IV (1 stated IV works better)
Staff reported that administering IV medications is significantly more resource-intensive than oral alternatives, involving multiple steps such as drug preparation, double-checking procedures, documentation, flushing lines, and safe disposal of packaging and sharps. This process increases workload and reduces time available for direct patient care. IV administration is often chosen out of habit or perceived efficacy, despite limited line access and time constraints.
Unfortunately the data was unavailable to measure the impact of extending hanging times. This is something that the team wish to continue to promote and plan to collate this data in the future. The team plans to review the practice of line removal (for around 2,200 patients per year). The hope is that where the enteral route is embedded in staff behaviours, there may be scope to remove IV lines sooner and further progress could take place exploring other themes around patient safety and improvement.
To ensure lasting change, the team have taken additional steps to revise the prescribing border set. Once the patient is beyond 24 hrs, oral medication will appear as the only route prescribed. Plans to review on-going medication usage and costs are in place. The team has set up monthly reviews and will host regular meetings with the critical care pharmacist and unit manager. The Critical care procurement lead will monitor consumption data over the next 6-12 months.
The team have championed safe, more appropriate decision-making by promoting enteral medication routes where possible, thus reducing the need for IV administration, and identified that IV lines for particular medications, do not need to be replaced more frequently than every 72hrs.
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