Nurses Responding to Patient Symptoms Improving Outcome Trajectory for Headache Patients Treated With IV-DHE

Chronic pediatric headache is a disabling disorder that at times may require inpatient care (Marmura et al., 2015). Intravenous dihydroergotamine (IV-DHE) has emerged as an effective treatment for chronic headache disorders (Nagy et al., 2011). Positive outcomes were also found in a study examining the efficacy of IV-DHE in pediatric populations (Kabbouche et al., 2009).  Throughout our practice offering admissions for IV-DHE to our patients, multiple problems have arisen that we addressed to improve outcomes and patient safety. A selection of these problems and solutions are as follows: (1) Patients were referred for admission without proper testing or a full evaluation (i.e., an assessment but both a neurology attending and a psychologist).  We addressed this by creating an educational guide for optimal IV-DHE admission at our hospital to provide to the referring clinicians. (2) Due to prior adverse reactions, there was a need for psychology screening prior to inpatient admission but the hospital’s psychology resources were limited.  Our solution was to create an intake triage screening protocol to ensure patient safety.  (3) We noticed a consistent side effect of nausea and/or vomiting in our patients.  To address this, we added a pre-bolus of D5-½ NS to address the potential issue before it started. (4) There was a significant delay between the morning test dose (half of a full dose) and the first full dose, thus delaying the pain relief and lengthening the patient’s stay. To start treatment sooner, when there were no adverse reactions to the test dose, we began to give the second half of the dose one hour after the test dose. Prior to this change we were waiting eight hours for the first does to be given after the test dose. (5) Due to the nature of DHE on the veins (i.e., potential for irritation, infiltration, and vasoconstriction), we would often lose access to the first peripheral IV (PIV) and need to reinsert it on the inpatient unity which oftentimes would be traumatizing to the patient. To address this, we altered our standard of practice to include the insertion of two PIVs prior to treatment using numbing creams and under the optimal conditions of the infusion unit to reduce the patient’s emotional trauma.  These five problems and solutions are just a sample of the lessons we have learned over the course of our work that have led to an improvement in outcomes and patient safety.  These changes have led to a reduction in pain such that 68% of our patients were assigned a discharge status of “Improvement,” with 26.3% of all patients completely headache pain-free upon discharge.  Further, these changes have increased the overall safety of our patients and minimized adverse events.