Lost Time Is Never Found Again: Ensuring Pre-Delivery AZT Infusion for HIV Positive Mothers
- Describe standard of care for zidovudine administration prior to cesarean delivery
- Identify three potential delays to timely zidovudine initiation
- Describe two interventions which can effectively reduce delays
Current standards of care call for intravenous zidovudine (AZT) 2 mg/kg over the first hour, then 1 mg/kg for at least 2 more hours before delivery. This significantly reduces MTCT of HIV. However, even admission for a scheduled cesarean delivery does not always go smoothly, and many of these women were not receiving the full recommended dose.
Proposed change: Our goal was to improve successful administration of the recommended dosing for these mothers. We had a motivated, multidisciplinary team: both HIV nurses and Labor & Delivery nurses, an OB/GYN physician in the HIV clinic, the Perinatal Education team, Nurse Managers, and Pharmacists.
Implementation, outcomes and evaluation: Time was not on our side. Patients were told to arrive 4 hours prior to scheduled cesarean delivery. This gave us only an hour to get the mother admitted and have the AZT started. Any of a number of issues could delay quality patient care. Some women did not arrive on time, and many of these women did not have good veins. Time was lost trying to obtain orders and the infusion from Pharmacy. These resulted in one unfortunate ending: the mother was inadequately treated, increasing the risk of HIV transmission to her infant. Strategies implemented included instructing the woman to arrive 6 hours prior to scheduled delivery time and the HIV physician began placing orders on the unit the day before admission. We could then send for the AZT infusion the minute the patient arrived. The results were immediately obvious. The results of the implementation were a significant improvement in patient time of arrival, a reduction in delays obtaining orders for the AZT infusion (mean of 45 minutes to 0), and decreased time until start of the AZT infusion (mean of 120 minutes down to 90 minutes).
Implications for nursing practice: T here is still room for improvement, as obtaining timely intravenous access continues to be a challenge. Our next step will be to place a priority on obtaining IV access, so if there is difficulty, it is determined early and quickly. We continue to strive for 100% quality outcomes and sustain these changes.
Keywords: HIV, performance improvement, multidisciplinary team, mother-to-child transmission
