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Aurora St. Luke's Medical Center

Presentation Notes

Quality Improvement podium presentation at Nursing Passion: Re-Igniting the Art & Science, Advocate Aurora Health Nursing & Research Conference 2022; November 9, 2022; virtual.


Background: A large tertiary care hospital in the Midwest manages care for approximately 200 patients with implanted intrathecal pain pumps. Nurses perform the high-risk task of refilling these pumps with highly concentrated medications. An inherent risk, with the potential for adverse events, of this process is a “pocket fill” where medication inadvertently leaks into the surrounding tissue. A pocket fill can cause overdose symptoms including death if not treated promptly.

Local problem: In 2020, there were 752 intrathecal pump refills with 3 reported pocket fills. Two patients required hospital stays. This was an increase from 2019 when there were 834 intrathecal pump refills and 1 reported pocket fill.

Method: Pain management nurses and leadership conducted an apparent cause analysis of the intrathecal pump refill process and post-procedure care, with input from quality, patient safety, pharmacy, pain management providers, and clinical informatics. The team collected data, reviewed existing research and medical device literature, and surveyed other organizations. Based upon the review, a group of interventions were put into an action plan. Interventions implemented including written informed consent prior to each pump refill, reinforcing patient education about pocket fills, prescribing and educating on the use of Narcan, observing patients post-procedure for 30 minutes, performing pre- and post- assessments of level of consciousness and gait/ambulation, and recommending that all patients be discharged with a responsible adult for transportation and continued observation for 3 hours post refill.

Results/Conclusions: Intrathecal pump complications improved in 2021, during which there was 1 pocket fill and 675 intrathecal pump refills. The increased post-procedure monitoring allowed the clinic to identify and treat the complication during the clinical episode of care.

Implications for practice: Nurses will continue to educate patients and require 30-minute post-procedure observation with expanded clinical assessments and risk mitigation interventions for all intrathecal pump refills.

Document Type

Oral/Podium Presentation




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