Ensuring the Smart Use of Smart Pumps


March 2011 - Vol. 8 No. 3 - Page #30

Intelligent infusion device . . . decision support infusion . . . smart pump . . . regardless of the name used, what makes this equipment so smart? These pumps provide clinical decision support at the point of care, employ a library of medications customized to meet an organization’s needs, and are able to calculate weight-based infusion rates. Patient safety is enhanced through alerts or hard-stops when pumps are set outside the established dosage ranges in the library. The addition of analysis software to smart pump technology will enhance quality improvement (QI) activities.

However, these pumps are not smart on their own—humans must choose to use the safety features of the pump to reap the benefits. In the quest to reduce error and prevent patient harm, this is a critical point of understanding. Whether beginning or continuing the smart pump journey, here are some helpful tips for improving patient safety.

Library Development is a Team Sport
The library must be accurate and comprehensive in order to best use the smart features of the pump for patient safety. Incomplete or poorly designed libraries can lead to workarounds and defeat safety efforts. To avoid this, team players should include pharmacists, nurses, and physicians, as well as other potential pump users. Their expertise and experience will be needed to complete the following tasks:

  • Review the data elements required for the library, including drug name, dosing units, upper and lower dose limits, concentrations, and designation of care areas.
  • Create a list of all medications that may be administered using the pump. Provide standard concentrations and volume dispensed, if needed.
  • Document dosing methods for medications. If weight-based, specify the units used.
  • Review all standard order sets, protocols, policies, and procedures associated with medications on the list. Should inconsistencies be uncovered, use the team to build consensus.
  • Formulate a plan to deal with those medications that are used in different areas or by populations that may require deviation from the standard. For example, anesthesia may have a rationale for a different concentration of epinephrine than other care areas. The pediatric care area may use weight-based dosing (mcg/kg/min), while other areas use mcg/min. Consider different indications that require different concentrations; one example in our library is vasopressin, where different concentrations and dosing limits are used for shock versus gastrointestinal indications.
  • Review, review, review! Have team members review their sections in detail. Ask pharmacists outside the team to do a comprehensive review. If your vendor offers an independent review, accept their offer. Each review is another opportunity to ensure better safety for patients.
  • Create the library for the pump. Be sure at least two individuals have access to the software and the necessary knowledge to adjust the library, in case of emergencies or personnel changes. We had an emergency that made it necessary to replace our library in one day; this was successful, in part, because we built in this redundancy. Two pharmacists initially built the library together, but when the event occurred, one pharmacist was out of town. The other was able to quickly pull together a team to assist with decisions, and then build the new library.
  • Test all medications in the pump with nursing and other primary users (such as anesthesia) prior to finalizing the library.


Data Review—Unleash the Power!
Implementing smart pump technology is only part of your safety armory—the library features must be used in clinical practice to reap the benefits. Routine review and assessment of QI data will help keep the pump safety system running smoothly.

  • Note that event logs are not the same as QI data. Event logs provide a historical review of an individual pump’s transactions, which is useful for documentation or investigation of equipment failure or an adverse event associated with that one pump. QI programs, on the other hand, provide real-time, historical data reportable for individual and multiple pumps in the system, with various data points such as medication, alerts generated (eg, outside of recommended dosage range), and the response to those alerts (eg, override or reprogramming).
  • Reviewing and assessing data for trends allows fine-tuning of the library and evaluation of usage patterns to improve safety. If QI programs are not available, routine audits should be performed.
  • Consider expanding access to QI data to key nurses, pharmacists, and performance improvement or other staff for routine review of specific data elements and quick turnaround of feedback. For example, TJC national patient safety goal for anticoagulation management can be enhanced by daily review of pump data to ensure the library is engaged for heparin infusions.
  • Use the incident reporting system to screen for events related to pump use. For any event report involving IV administration, always ask if the pump was used to its maximum functionality and could use of the pump have prevented or contributed to the occurrence. Plan your assessment and actions accordingly. 


Be a Catalyst for Change
In April 2010, the FDA launched an infusion pump improvement initiative in response to numerous reports of pump-related adverse events and device recalls.1 This project will undoubtedly facilitate device improvements, increase user awareness, and establish additional requirements for infusion pump manufacturers.

Smart pump users can contribute to this progress by sharing experiences and suggestions with vendors, the FDA, and professional organizations. The FDA has stated that many infusion pump problems are related to issues with device design and engineering, and pump users can provide valuable insight to improve these problems.

While it is easy to see the powerful potential for patient safety improvements in connecting infusion pumps with various medication management technologies, few of these interfaces currently exist. Efforts to design, build, and test interfaces and new functionalities will lead us to the next generation of “smartness.”

Reference

  1. US FDA Web site. Medical Devices: Infusion Pumps. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/default.htm Accessed February 15, 2011.

Deb Saine, MS, RPh, is the medication safety manager at Valley Health/Winchester Medical Center in Winchester, Virginia. She has authored numerous articles and has presented internationally on the topic of medication safety, serves as chair of the ASHP Council on Pharmacy Practice, and is the past-chair of the ASHP Medication Safety Section Advisory Group. Deb received her BS in pharmacy from the University of Toledo and an MS in management from Antioch University.


Smart Pump Selection Tips

Identify stakeholders and involve them in the selection process. Be sure to invite clinical personnel (nurses, pharmacists, physicians), representatives from purchasing and distribution (central supply, finance), biomed, information technology, risk management, quality improvement, transportation, and an administrator for project support.

Ask who, what, where, when, why, and how? For example, consider the hospital’s patient population. Will the pump serve adults only or pediatrics as well? Define the intended use of the pump—will it encompass large volume infusions, PCA, epidurals, the NICU, pediatric patients, palliative care, and anesthesia? Will it be used for bolus doses as well as infusions? These important distinctions will influence pump choice.

Determine criteria for assessment and create an evaluation tool. This will guide an objective assessment to compare pumps. Invite all the stakeholders to weigh in. Examples of criteria include battery life, number of concentrations allowed per drug, display features, wireless capabilities, and vendor support/customer service. The more comprehensive and detailed, the better the assessment—which will help avoid surprises later on in the process.

Once pump choices have been narrowed, invite vendors to demonstrate their products’ capabilities for all stakeholders. Use the evaluation tool created to document the pros and cons of each pump.

Research the pumps being considered. Seek out information using publications, the experience of colleagues, GPO resources, independent research evaluations (eg, ECRI Institute, KLAS), and site visits.

Conduct a hands-on evaluation of top choices by users. Develop scenarios for the front line staff to use for evaluation and feedback.

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