Utilizing smart pump technology effectively undoubtedly improves medication safety by decreasing the possibility of IV administration errors. Because 56% of medication errors are associated with IV medications—and of those, 61% are serious or life threatening—integrating robust smart pump technology can have a significant effect on patient safety.1-3 Smart pumps improve safety as they provide insight into near misses or actual errors, which are oftentimes extremely difficult to detect without this technology. Smart pump data allows improved, more targeted practice improvement efforts.
However, smart pumps by themselves are of limited utility; their benefits must be considered in conjunction with the larger, integrated system. Smart pumps should ideally be integrated with the electronic health record (EHR), as this permits in-depth data analysis of treatments and their sequence of events. The capacity for smart pumps to interact and communicate with the EHR is a key functionality consideration. Also, the ability to eliminate smart pump programming requirements as much as possible should be a prime consideration when implementing a system.
Securing Multidisciplinary Support
When creating a fully integrated infusion management system, securing administration and departmental leadership’s support for the initiative early in the process is paramount. Secondly, work closely with the IT department to ensure that the necessary infrastructure exists at your hospital to support the numerous changes required for full integration. For example, does the IT infrastructure have the capacity to handle the additional data traffic? Is there sufficient staff to support the testing of the new software and upgrades?
As in any complex initiative, broad multidisciplinary cooperation and a thorough process are required for an effective outcome. Meet with the relevant stakeholders and come to consensus regarding the desired functionality of the system. Several questions must be answered; for example, should all pertinent information be sent from smart pump to EHR, or only partial information? Should that information be sent back to the EHR? If the pumps are not bar coded, it may be necessary to involve a vendor to complete this task. After consensus has been reached, meet with your vendor to determine if they have the capacity to provide the level of integration you are requesting.
Features of a Robust EHR System
With full EHR/smart pump interoperability and integration, nurse programming time can be significantly reduced, as can reprogramming time when an alert fires. Consider whether the capability exists to communicate the drug, the concentration, and the dose, as currently, not all EHR systems are capable of delivering this level of functionality. Therefore, at a minimum, choose a system that communicates the drug and concentration and provides assurance that end users are engaging the drug library and utilizing the pump. Although programming the pump incorrectly is still a possibility, at a minimum pharmacy can verify that staff are utilizing the pump and drug library.
Measuring the Impact of Smart Pumps on Patient Outcomes
Gauging how smart pumps improve patient outcomes is challenging; although these are intelligent devices, depending on the capabilities of your EHR vendor, data may not be linked back to an individual patient account. Non-patient–specific data is useful to determine error trends over time, but not particular patient outcomes. Enhanced smart pump/EHR integration improves the capacity to track and evaluate outcomes for specific patients.
Carefully evaluating and editing alerts, especially overrides, can have a positive impact on patient care. For example, if a large number of alerts are being overridden, it may be due to improperly trained staff—or perhaps the programmed alert criteria are too stringent. Tracking the use of overrides allows pharmacy to more effectively develop appropriate alerts, reducing possible alert fatigue.
The Changing Role of Pharmacy
Once high-level communication between the smart pumps and EHR is attained, the role of pharmacy changes to include the possibility of reviewing doses that have been populated on the pump, including profiling rate changes. Therefore, pharmacy is able to increase ownership of the process. Medications to consider first include heparin, straight infusion (those without frequent titrations), and large IV fluids. Address those therapies that have the most potential to cause harm, but yet have dose titrations that are manageable by pharmacists. Most importantly, do not impede upon or interfere with patient care.
Benefits of IV System Interoperability
Striving for improved interoperability between the smart pumps and the EHR provides many advantages. It guarantees the selection of the correct medication from the drug library, as well as ensures dose limit checking against the library limits. It eliminates manual programming of the medication, concentration, dose/rate, patient weight, and volume to be infused, removing the inherently error-prone human element, and requires the nurse to focus on one IV medication at a time, further improving medication safety. Ideal IV interoperability also allows automatic programming of drugs that are not already in the drug library, as well as pharmacist validation of the provider-ordered dose and infusion rate, a second review by the nurse, and fosters a collaborative culture between pharmacy and nursing.
Although the multifaceted process of increasing communication between technologies may appear daunting, careful planning and gaining buy-in from the key stakeholders involved will best ensure a seamless process.
Amanda E. Prusch, PharmD, BCPS, is the medication safety specialist at Lancaster General Health. She has a practice interest in anticoagulation and other high-risk medication use, and also leads the Clinical Medication Safety committee at Lancaster General.
Incorporating Evidence-Based Standards in IV Practice
Clearly it is important to incorporate evidence-basedstandards throughout the IV medication process, fromordering to titrating and administration. Although a large bodyof evidence-based standards has not yet been developed, pharmacy is nonetheless responsible for researching the available data and creating in-house standards that will dictate IV practice expectations for clinicians. If no standards have been delineated, nurses will often titrate medications differently, leading to a lack of standardization in IV medication administration.
National guidelines or best practices, where they exist, should be reviewed as a starting point to develop institution- or health-system–specific standardized concentrations and dosing limits. Developing and utilizing standards that are health-system–specific is an obvious next step. For example, complication sometimes ensues during transitions of care, especially when a patient is moved to a facility outside of the health system. A patient taking heparin, for instance, titrated to one concentration, may be given a different concentration after being transferred. Therefore, the development of standards—whether they are national, regional, or institution-specific—is an ideal goal.
When developing evidence-based standards, also keep in mind any recent drug shortages and include an alternate plan to utilize if a first-tier medication is unavailable.