By Richard Paoletti and Amanda Prusch
In an effort to improve medication safety, Lancaster General Health, a not-for-profit health care system in Lancaster, Pennsylvania, decided to implement intravenous (IV) interoperability. IV interoperability, also termed auto-programming, is a nascent technology that links smart pumps with bar code medication administration (BCMA) and electronic medication administration record (eMAR) systems. With auto-programming, a smart pump is automatically populated with pharmacist-validated, provider-ordered infusion parameters, thereby eliminating the need for the nurse to manually program the pump. This adds a safety check that helps decrease the likelihood of a medication error during the administration process. While bringing this technology onboard was a monumental task that took several years to complete, it has had a substantially positive impact on workflow and patient safety.
In 2005, we decided to institute smart pump technology at our hospital. Shortly after, we were approached by our BCMA/eMAR and smart pump vendors to see if we would be willing to be a beta site for the development of IV interoperability. After 33 months of extensive testing and validation of the technology at various stages by a multidisciplinary team consisting of vendors, our core hospital development/validation team, and hospital end-users (both pharmacists and nurses), a pilot was launched at our hospital on a cardiac-telemetry unit; the unit was chosen because it offered predictable types and volumes of medications. Within four months, the project was expanded to include two additional nursing units in order to test the technology in environments that offered an increased variety of IV medications.
While in the pilot phase, a time and motion study was conducted to compare the manual pump programming process to the interoperability system. The study demonstrated a 24.8% (p < 0.0001) reduction in nursing time needed for the interoperability pump programming process compared to the manual process, and workflow was streamlined from 17 programming steps to seven. In addition, there were several examples of pump mis-programming during the manual process that were eliminated by the auto-programming system. For example, nurses had manually programmed the patient’s weight as the dose, or selected the wrong line item in the drug library.
Prior to moving the roll-out past the pilot stage, we had to validate and install software upgrades from both vendors as well as undergo a hardware upgrade on the pumps to enhance wireless communication with our network. We then rolled out the new technology to our remaining telemetry units over two weeks, followed by our medical/surgical units over the next six weeks. Implementation was strategically planned to expand on a unit-by-unit basis to allow for hands-on training and real-time resolution of any problems.
After instituting IV interoperability, the telemetry units’ compliance to the drug library increased by greater than 30% (p < 0.0001) and the medical/surgical nursing units’ compliance rate increased by 83.4% (p < 0.0001). As compliance to the IV interoperability software increased, the number of violations to the soft and hard dose limits that prompted the nurse to reprogram the pumps decreased, with telemetry and medical/surgical drug libraries demonstrating a reduction of 94% (p < 0.0001) and 97% (p < 0.0001), respectively. In July 2009, IV interoperability was used with 12,020 IV medication administrations, demonstrating a successful auto-programming rate of 90%. Through the integration of the systems and the incorporation of pharmacist oversight for all rate changes, the telemetry and medical/surgical patient care areas demonstrated a 60% reduction in reported monthly heparin IV administration errors.
While implementation of this new technology went fairly smoothly, there were some challenges that we faced during the initial testing and pilot phases.
Smart Pump Warnings
One of the issues we encountered during the software validation phase involved smart pump warnings. We discovered that we had to modify upper soft limits for certain medications in the auto-programming drug libraries to account for total volume. Since the pharmacy information system populates the BCMA/eMAR system with the total volume that accounts for the additional volume from the medication added, certain medications would fire the upper soft limit warning for the nurse. These medications were identified during testing and the upper soft limits were adjusted so that the warning would not fire as a result of that total volume. By addressing this issue during testing, these warnings were not a concern post-implementation.
Bar Coding the Hardware
Another challenge that we faced dealt with the actual bar coding of the pumps. Each pump has two channels—an A and B channel. The pumps are not equipped with unique bar codes to identify these two channels, so we had to engage a third vendor to develop durable, channel-specific bar-codes that could withstand environmental exposure such as routine cleaning. In addition, we had to develop procedures for initial pump labeling as well as subsequent relabeling as needed.
After going live on the pilot units, we recognized a setting on the pumps that defaulted to the power-save mode causing the pump to “go to sleep” for short periods of time to conserve the battery, resulting in the pump dropping communication with the network. To assure constant communication with the network, the configuration had to be changed to a continuous mode. In addition, the connectivity engine on the pump was upgraded to optimize the pump’s ability to communicate with the network.
These upgrades required a major coordinated effort as we had to pull back more than 900 pumps to make the setting changes. During the pilot phase we also discovered that the original placement of the channel-specific pump labels—on the front face of the device—led to increased environmental exposure. So, we also took this opportunity to move the channel labels to the top of the infusion device, a more optimal location to minimize wear and tear.
Although we have a small percentage of auto-programming attempts that fail, we investigate each failure to identify its root cause. We have found that these failed attempts are primarily due to wireless connectivity issues or pumps that did not have the appropriate hardware settings changed to permit better communication between the two systems.
Improved Compliance Monitoring
One of the major advantages of IV interoperability is that electronic documentation of the entire IV medication administration process is available. We can now identify practices that could previously only be discovered through direct observation. For example, prior to IV interoperability, we could not monitor individual user compliance with the drug library. Now, we are able to generate a report from our BCMA system that indicates each nurse’s compliance with the IV interoperability software. The nurse managers then receive a monthly compliance rate for each nurse. The report allows us to distinguish between a technology/system failure and a user bypassing the technology.
In order to better facilitate compliance with the system, a plan for ongoing direct observation of users to check for workarounds, non-compliance with intended procedures, and bypassing the system should be developed well in advance of the go-live. Nurses must be educated about the system benefits, and, at times, one-on-one training is necessary to ensure appropriate procedures are followed.
By adding pharmacist oversight to the medication administration process, we have demonstrated that safe IV medication administration does not rest solely with the nurse at the bedside. This approach strengthens the collaborative relationship between pharmacy and nursing and provides patients with a safer medication experience.
Richard D. Paoletti, MBA, RPH, is vice president of operations at Lancaster General Health. Prior to this, he served as director of pharmacy services at Lancaster. Richard received his bachelor’s degree from the Philadelphia College of Pharmacy, and an MBA from the University of Delaware.
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 co-chairs the Medication Management and Clinical Medication Safety committees at Lancaster General.
FINDIT: Smart Pumps
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