056. An audit of protocol for the IV Methylprednisolone infusions in the rheumatology day care unit

Abstract

Background: Methylprednisolone is a synthetic glucocorticoid drug used for its anti-inflammatory and immunosuppressive effect. Intravenous methylprednisolone (IVMP) is used in a number of different conditions including Juvenile Idiopathic Arthritis (JIA), Systemic Lupus Erythematosus (SLE), Juvenile Dermatomyositis (JDM), scleroderma and vasculitis (1,2). The current protocol used in our rheumatology day care unit was to administer the first dose of IV methylprednisolone (IVMP) over 4 hours, and subsequent doses over 1 hour. The monitoring included recording vitals, temperature, and blood pressure (BP) at base line and blood pressure = hourly for 1 hour, then hourly. The protocol was to observe patients 2 hours post infusion. We felt this appeared to be overly time-consuming and complicated. Aims: Compare the current protocol against clinical practice with a focus on patient monitoring and time, and any side effects. Our objective was to modify the protocol to safe, simple and ensure better quality. Methods: Retrospective study of new patients with Juvenile Idiopathic Arthritis who received IVMP as their first treatment during the year 2015 and 2016. Data collected from hospital notes using a proforma that was developed against the standards set in the protocol. Results: Monitoring targets were largely not met, with all patients had their baseline observations but only 17.4% had their BP monitoring = hourly. The time between observations were variable. 35% of patients were kept for the two-hour post-infusion period, with only 63% of these having observations recorded on discharge. Protocol for infusion duration was not followed on 6/69 days that methylprednisolone was administered, with no explanation given for 4 of those days. None of the patient in the study experienced a significant adverse reaction. Conclusions: With no significant adverse reactions to Methylprednisolone, we believe less frequent observations rather than every 15 minutes may ease off staff work load with no increased risk to patient safety. We recommended reducing the duration of the infusion to hourly rather than 4 hourly unless there are comorbidities like renal problems, hypertension etc. We also proposed optimising the monitoring required in to a standardised set and to incorporate the PEWS chart in to our proforma to avoid duplication. A new protocol had been developed incorporating the recommendations following this project and will be re audited in future.