When it comes to technological updates in a hospital pharmacy practice setting, there is a full range of expected (and unexpected) challenges that accompany process and workflow changes. In some cases, as with large-scale, multifaceted conversions to CPOE and BCMA, it can be difficult to know where to start, which breeds procrastination. However, as with any long journey, it is often better to break a large project into short-term goals; in 2007, our overarching goal was to implement BCMA for all medication doses. To begin this project, we wanted to start with the greatest risk area, so we set an initial goal of integrating bar code scanning into the IV administration process using smart continuous IV infusion pumps.
Angel Medical Center is a 25-bed, nonprofit, critical access hospital located in Franklin, North Carolina. We operate a centralized pharmacy distribution model, and staff 2.4 pharmacist FTEs and 4.2 technician FTEs. We began using smart IV infusion pumps in June of 2007 and while we did experience difficulties in integrating the system, we have effectively leveraged our IV infusion processes to maximize the benefits of our smart pumps and they continue to protect our IV infusion process today.
Pump Setup and Programming
There certainly have been improvements and upgrades to smart pump technology in the years since we implemented our system, but many of the fundamental functions remain the same. The practice of populating smart infusion pumps with a drug library is one such function, and most vendors have stock templates that can be refined for your specific needs. We were able to select from hundreds of available drugs in our vendor’s stock library, all of which came with suggested dosage units and rates of infusion. The software also allowed us to choose from a specified list of usage areas, and given our patient make up, we selected three of the six possible areas—ICU/CCU, med/surg, neonate and pediatric. We then convened a multidisciplinary group of pharmacy and nurse managers to review drug references in order to verify the dosage forms and the minimum and maximum infusion rates for each drug in each setting. In this process, our vendor representative again assisted us by giving input as to what the typical limits were for most drugs, and we were able to compare ours to reveal any discrepancies and either correct or justify them. Once we reviewed all the IV infusion drugs in use at our facility, we had the parameters loaded into all the infusion pumps for deployment.
Among the differences between the various smart pump systems on the market is the means by which the system is able to update the drug library. In our case, we do not have the capability to wirelessly update the library, so changes have to be made in bulk by recalling all the pumps and performing a wired update. The ability to wirelessly push out drug library and other updates to the individual pumps provides greater flexibility and less physical labor versus a wired system.
Regardless, the greatest benefit of our smart pump technology is enabled by the bar code scanning interface. Though we are not able to wirelessly send information to the pumps, the pumps do send usage information out wirelessly. This approach introduced our staff to bar code medication administration, and we found it to be a valuable area to begin such efforts. To enable this process, we programed our pharmacy information system (PIS) to print new labels with a specific bar code array. On each IV dose label there are a total of four bar codes, three of which transmit information through the smart pumps, and one that passes information to our PIS. Because our smart pumps cannot communicate directly with the PIS, we need to have two separate scanners—one for the smart pump and one for the PIS (see Figure 1).
Using the figure 1 label as an example, the pharmacy receives an order for Ceftriaxone 1 g for injection in 5% Dextrose, 50 mL bag. The PIS will print out a label that contains all applicable information for the infusion it is attached to. When the dose is being administered, the attending nurse will scan the bar codes, which programs the pump, and in turn, wirelessly transmits the infusion information in real-time to computers in the pharmacy. From my desktop computer, I am able to view all infusions that are currently running, and if the bar codes are properly scanned or the drug library is used to program the pumps, I can see all relevant information for that infusion. Initially, we were concerned that having two separate scanning mechanisms would lead to lower scanning compliance from nursing, but we have seen that by indoctrinating the idea that bar code scanning provides a high level of safety and protection for both patients and staff, our nurses bought in and are willing to follow the steps accordingly.
Dual Methods of Administration Verification
We have had success in getting nursing staff to use the scanning systems in place, but arguably the largest challenge is getting nursing to maximize the use of the available features. Enabling nursing to scan dose label bar codes to establish the five rights streamlines the process, but not all products have bar codes, so supplying a robust drug library and providing proper education and reinforcement of training on the importance of programming the pumps in lieu of bar code scanning is vital. If this process is encumbered by unnecessary steps or unavailable drug information, compliance with valuable infusion safety measures will suffer. By giving nursing two viable options for programming the pumps, there should be no excuse for noncompliance.
Once an IV medication is ready to be administered, the nurse should scan the lower set of three bar codes on the drug label (see Figure 1) to populate the pumps with relevant data. In the event an IV dose does not have a label or set of bar codes—as can sometimes be the case with admixture products kept in ADCs, which are used after pharmacy hours, the nurse should search the drug library to match the dose. This is a clear benefit of having all IV admixture products listed in the drug library. As the pharmacy director, in my office looking at my computer screen of infusions, I have no idea if a product is high risk or otherwise requires extra surveillance or review if it is neither scanned nor programed from the library.
Focus on Lead Up to Integration
The most important element in integrating smart pumps into your medication administration process is to construct a detailed, step-by-step implementation plan, well ahead of time. We began using our smart pumps shortly before The Joint Commission issued its sentinel alert on safely implementing health information and converging technologies—TJC Sentinel Event Alert, Issue 42, 12/2008. Included in that alert is a list of 13 suggested actions to be taken or considered prior to any technological implementation in the hospital, including the pharmacy (see Figure 2). This would have applied well to our smart pump implementation and we adopted these suggestions in the form of a 13-step checklist for subsequent implementations.
Education and a clear vision of purpose can go a long way in enabling staff to follow all policies and procedures when it comes to the operation of new technology. Vital to the effectiveness of good education is electing a continuous administrative champion. In our case, our CNO took it upon herself to acknowledge that if we were going to spend money on smart pump technology, we should spend equal effort relaying our expectations for safety, educating staff on use, and tracking and reporting user data to reinforce that education. Because we can present usage data to see when and where proper safety measures are (or are not) being used, we have nurtured a friendly competition between departments. If outpatient medicine can average 95% compliance in a given month, why can’t the med/surg department? In the end, all facilities should emphasize that adherence to procedure can reduce liability and increase patient safety. Our head ICU nurse also was a great proponent of the safety bar code scanning brings to the process and she has put forth great effort to increase scan rates for all administered doses, not just IVs.
Make Use of Reports
All of our smart pump usage data, including errors caught, is compiled and reported on a monthly basis, but some infusions, notably high-risk infusions, we actively monitor at the time of infusion. In fact, we are now moving toward evaluating data on heparin infusions in real-time as opposed to after the fact as a quality assurance measure. When a heparin infusion is hung—an event I am aware of because I receive an alert from the PIS—I will physically walk to that room and make sure the nurse programmed the infusion using either the drug library or bar code scan, and that everything is accounted for. While high-risk medications require special care—all high-risk infusions are bar coded without exception—I should be able to look at my computer screen and see every single active IV infusion so I can make informed decisions as to what to follow up on. I know, for example, that if the drug name appears there, that the nurse either programmed the drug into the pump or selected it from the library. In either case, I also will see the pump ID number, the rate of infusion, and how much drug is left to infuse. If the nurse properly scans all three of the IV bar codes on the lower, smart pump portion of the IV label, as well as his or her ID badge, it will also display the patient’s name and the administrating nurse’s name. While this is information we would like to have for all IV infusions, we certainly want to make sure it is there for high-risk infusions.
In addition to the monitoring of infusions and reporting on errors avoided, I run a weekly report on all aborts that take place during the administration process. Whenever an alert indicates there is a discrepancy between what the nurse has entered into the pump and the pre-selected minimum or maximum for that drug, we want to know the conditions of that override. As a machine cannot make clinical decisions, we must allow our nurses to have the ability to go out of set ranges if it is therapeutically relevant. A common scenario is when we are titrating a patient off a medication. In such a case, the nurse might want to override the lower limit of the drug to allow for that titration. It is important to review such incidences, because you may need to reevaluate your minimums and/or maximums. Due to the number of drugs that may be administered through smart pumps and the variety of patient-dependent situations, there will certainly be times when necessary adjustments become apparent only after a period of experience. When we were first administering propofol through the pumps, we established a particular set of units—milligrams per kg—but realized after a short period of time that doctors were primarily ordering it in a different set of units—micrograms per kg. So the numbers entered into the pumps were causing frequent alarms that needed to be overridden. This was a cue to reevaluate how the pumps were handling propofol and align them with actual practices.
Smart pump technology has evolved substantially in the last few years and if you are looking to upgrade your system or add this technology to your practice, it is worth taking the time to review as many options as possible. Given that the technology will continue to evolve, it also would be beneficial to consider a lease program instead of outright purchase, depending on your needs and budget capabilities.
When it comes to the due diligence required from the onset, I cannot overstate the importance of involving staff pharmacists and nurses in the selection process. At the time of our acquisition, neither the pharmacy department nor staff nurses were included in the decision-making process, and I think the program suffered because of it. Having constructive, operational input from front-line practitioners will surely limit complications further down the line.
It is now to the point that smart pumps are offering two-way communication with pharmacy information systems. This should enable such a system to not only confirm that the correct drug, patient, and infusion rate have been selected, but it also would directly program the pump (eliminating the need for a separate bar code for the PIS), allow the pharmacy director to view all active infusions in real time including the pump’s location, and create a thorough audit trail for all infusions. In addition, drug library updates could be wirelessly pushed out at any time, further incentivizing administering nurses to use the library.
Debra Cowan, PharmD, RPh, FASHP, is director of pharmacy at Angel Medical Center in Franklin, North Carolina. Debby received her BS in pharmacy from the University of New Mexico and her PharmD from the University of Colorado.
Figure 2. The Joint Commission’s Suggested Actions
Below are suggested actions to help prevent patient harm related to the implementation and use of HIT and converging technologies.
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