While 72% of health systems use intelligent infusion pumps,¹ it is not simply the implementation of these smart pumps that provides an increase in safety; rather, it is the effective, ongoing management of the accompanying drug libraries that allows us to continually improve the care we provide to our patients. To ensure both patient safety and workflow efficiency, establishing processes to properly manage and update smart pump libraries system-wide is vital. 

After implementing smart pump technology in February of 2008 at Women and Children’s Hospital, a 220-bed facility in Buffalo that is part of a five-facility health system, we found managing revisions to the smart pump drug library to be a complex, continuous process, requiring input from a multidisciplinary team, and—because our hospital serves both adult and pediatric populations—the approval of our pediatric P&T subcommittee. The majority of our beds are pediatric, including a 20-bed pediatric intensive care unit (PICU), which is also a regional trauma center. There is a 64-bed neonatal ICU, which admits more than 700 patients a year, 200 of whom are transported from other facilities in an eight-county area surrounding Buffalo. We are also a designated high-risk obstetrics center with fetal maternal medicine consultations and a hotline. 

Coordinating the process of updating the drug libraries throughout this vast system proved to be a challenging process that required a systematic approach to ensure we realized the full safety benefits of this smart technology. As clinical coordinator, I was involved in the initial implementation and rollout of the smart pumps and am responsible for managing updates to the smart pump drug library for both the pediatric hospital and pediatric populations in our health system’s four other hospitals, with particular care given to critical care areas. 



Coordinating Drug Library Updates
Requests for changes to a smart pump library are generally driven by recommendations from members of our multidisciplinary team: nurses, nurse managers, nurse educators, physicians, and other pharmacists. We also consult and assess our facility incident reports, FDA and ISMP warnings, and formulary additions and deletions, and monitor listservs and literature for relevant information regarding smart pump libraries. Direct observation is also useful in determining what changes may be needed; during rounds, observe staff using the smart pumps to ascertain any problems and identify whether workarounds are occurring that must be addressed.

Several factors must be considered to determine whether or not an addition to or a deletion from the drug library is needed. Initially, the risk versus the benefit of adding the entry is weighed, in consultation with the nurse educator, the nurse manager, the medical director of the affected unit, the clinical pharmacist that performs rounds in that unit, the pharmacists or pharmacy manager responsible for information technology, and our co-chair for pharmacy and therapeutics. The feasibility of the change needs to be carefully considered; for instance, evaluate whether the drug is compatible with the dosing limit specified in the software, how the drug might be used for a specific patient versus the general population, and the future usage of that entry in the drug library. Consider factors such as whether the drug will be used just once for a single study patient or whether it will be administered frequently, and note any high-alert medications that must be specified as such in the drug library. 

Women and Children’s Hospital does not use a specific form to gather information for review of the potential drug entry; rather, there are 41 possible fields included in our software program that are used as a checklist to address the issues surrounding each drug. All fields relevant to the potential entry must be completed. The next step is to evaluate safety factors, such as drug concentration and look-alike/sound-alike potential. One way to manage look-alike/sound-alike entries is to review their ordering frequency and then place commonly used drugs in separate areas of the drug list. Indication can be added to the drug name in the pump as well. It is also important to confirm whether the minimum and maximum drug doses are compatible with the minimum and maximum infusion rates (at mL per hour) that the pump is able to deliver, and choose a concentration—if one does not already exist—that will meet the patient’s needs for fluid restriction, fluid requirement, and dosing requirement. 

After a drug is added to the library, nursing staff will not be able to accurately document the drug being infused if the smart pump data does not mirror that in the health system’s information systems. Hence, it is key to ensure that the concentration of the drug is listed in the same units in the IV pump as it is in the pharmacy information system and the EMR. Once the entry parameters have been determined, confirm the dosing limits of the drug in question using drug information software and primary references. In some cases it may be necessary to check specific references in the literature, and for drugs that are part of a study, be sure to review the study protocol. 

Gaining P&T Approval
Once consensus has been reached by all team members, the pediatric P&T subcommittee reviews the entry and provides final approval. This subcommittee is responsible for approving all drug library changes, as well as entry limits, rationale, and decisions that involve clinical care areas in which the entry would be implemented, such as the ICU, the emergency room, or on the general floors. P&T members meet monthly to discuss the potential changes and raise any concerns or questions. If drug library changes must be made more rapidly, due to a drug shortage or other extenuating circumstances, the P&T co-chairs approve these changes. 

Implementing and Communicating Changes
Once approval has been obtained, pharmacy works with the biomedical engineering staff to determine when the drug library entry will be pushed to the active pumps, as well as to communicate the timing of the change to the nurse educators and the nursing, medical, and pharmacy staffs. These two steps are critical, given the potential risks that can be introduced when changes to the library are implemented. 

While remote pushes are certainly more efficient than manual ones, we did discover a problem during a recent drug library push. Due to increased wireless traffic in our facility, the remote pushes were not being communicated to the pumps in a timely fashion. Because our software allows us to view the pumps that have been updated, it was apparent that some pumps in the system were not receiving the updates promptly; thus, two drug libraries co-existed simultaneously. Once we raised this issue as a serious safety concern, it became a priority for the biomedical engineering staff to address and push the updates through more quickly. 

The communication of drug library changes to clinical staff is driven by nurse educators, clinical pharmacists on rounds, and the clinical pharmacists on the P&T committee. It is important that the staff pharmacists be informed of any recent changes as well so that they can communicate those to nurses should they have questions about discrepancies between an order and the entry in a smart pump. 

Communicating updates to hundreds of nurses can be a challenge. They may be using workarounds to accommodate a recent drug shortage, for example, unaware that a new concentration of the drug has been added to the system in response to the shortage. Once nurses are made aware that a new entry exists, they can return to using the safety software as intended rather than using a workaround. Frequent communication from pharmacy to nursing is vital to prevent the use of these workarounds, which can potentially endanger patient safety.  

System Drivers
Drug library updates affect formulary, purchasing, CPOE, EMR, and ADC systems, and, likewise, changes in those systems can impact smart pump usage. Recent formulary changes driven by neuromuscular blockers on shortage, for example, required changes to the neuromuscular blocker entries in our pump system. 

The purchasing department must be made aware of the impact on infusion pumps when purchasing new or substitute products. In one instance, our purchasing department began sourcing PCA syringes from a new company, and as a result, the bar code on the new syringe did not match the bar code on the pump, so the PCA pump would not accept the syringe. We have worked to improve dialogue between pharmacy managers, drug library pharmacists, and the purchasing department so that any manufacturer changes are communicated immediately, allowing pharmacy to update system bar codes as needed and ensure a smooth workflow. 

Future Directions
We are currently planning to implement CPOE in 2012. The pharmacists managing the CPOE project are charged with ensuring that the units used in the electronic order sets match those established in our smart pumps. The CPOE order sets will be modeled after the data in the smart pumps and the pharmacy computer system. This method is similar to the process we used to successfully implement EMR earlier this year. This standardization carries over to our ADCs as well. Most of our IV pumps are used for large volume or continuous infusion; thus, the concentrations available in the ADCs match the units that are in the pharmacy information system as well as in the drug library. 

When new policies are developed, a requirement is generally included mandating that the drug library be updated appropriately. Our overall hospital policy indicates that if a drug library entry exists, and the safety parameters are established, then a smart pump must be used to infuse that particular drug.

Managing smart pump drug library updates is a complex process. Nonetheless, maintaining vigilance in evaluating and updating entries—while communicating these decisions to staff in a timely manner—ensures a smooth process for staff while simultaneously ensuring patient safety.

Reference

1. Trends in Smart Pump Adoption. The 6th annual state of pharmacy automation: results from PP&P’s 2011 national survey. Pharm Purch Prod. 2011;8(8):98.

Kelly Michienzi, PharmD, is a clinical pharmacy coordinator at Kaleida Health, Women & Children’s Hospital of Buffalo. She is a graduate of the State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences. Dr. Michienzi completed an ASHP accredited pharmacy practice residency from Kaleida Health, Buffalo General Hospital. 

Dr. Michienzi serves as co-chair of the pediatric P&T subcommittee and primarily practices in neonatal and pediatric critical care. She maintains the adult and pediatric drug libraries, and the standard concentrations for Women & Children’s Hospital of Buffalo. For leadership in this role, she and the team at Women & Children’s Hospital of Buffalo were awarded the ASHP Research and Education Foundation Award for Excellence in Medication-Use Safety in 2009.