The University of Pennsylvania Health System (Penn Medicine) includes six acute-care hospitals ranging in size from 250 to 800 beds, as well as hundreds of outpatient locations throughout the region. Penn Medicine is committed to being at the forefront of patient safety and innovation, and implementing interoperable smart pumps was key to these efforts. Two years post-implementation, the facility is now focused on optimizing key features in an effort to maximize the benefits of this technology.

Q: What is the value in implementing smart pump technology?

Melissa Augustino, PharmD, BCPS: Smart pumps are an important medication safety tool for ensuring the safe delivery of infusions. Smart pump technology promotes software builds that support good decision making when programmed with standard concentrations and optimized correctly. This results in less time required for manual programming, fewer opportunities for error, and, during medication administration, it is easier to control the rate of infusion and ensure that medications are being infused at rates that are safe for the patient and appropriate for the medication itself.

Q: What is Penn Medicine’s history with smart pumps?

Augustino: At Penn Medicine, we worked to implement smart pumps across the institutions, ensuring they are available in our nursing units and in our perioperative spaces to deliver consistency across all areas where care is provided. Additionally, we recently transitioned to the use of interoperability via a bidirectional interface. This feature has been live for about 2 years, and we have seen the benefit of having that extra layer of integration between the electronic orders and the smart pumps.

Interoperability

Q: When switching to interoperability, what are some tools that you used to gain buy-in from the other departments?

Augustino: To gain buy-in from other departments, we focused on the benefits provided by having the information in an order transmitted to the pump automatically. Adding interoperability allows for significant improvements in order accuracy and introduces a more streamlined workflow.

For example, interoperability is particularly beneficial for high-risk medications. We process a significant number of patient-specific orders, such as chemotherapy preparations, which require customization to the patient’s treatment regimens as well as their weights. In these cases, building a standard dose regimen in the library is not an option; however, with the benefit of interoperability, those custom orders for patient-specific doses can now be transmitted directly to the pump, easing the burden of manual programming for the nurse, and enhancing accuracy and safety.

When highlighting the benefits of interoperability, we also focused on how the technology will streamline documentation. In addition to the programming benefits it provides, the bidirectional interface also captures information. Since many of our pharmacists follow intake, outputs, and infusions, the information is much easier to locate when electronically captured. This also helps ensure that the information is up-to-date, enhancing pharmacists’ ability to complete clinical reviews.

Actionable Data

Q: What data metrics do you find valuable from a reporting perspective?

Augustino: We currently utilize several data tracking metrics and this is an area we are looking to expand. While it is widely recognized that time and resources must be dedicated to technology implementations, it is equally important to dedicate resources to ongoing system refinement and maintenance to ensure safety and efficacy.

To that end, nursing managers and leaders review unit compliance levels on a monthly basis with a focus on any medications causing difficulty at the unit level. If an issue is found, they then work with their team to identify potential causes and possible resolutions. This monthly review also helps identify issues should something in the build need to be corrected.

One issue we identified by examining monthly data patterns was problems with WiFi connectivity. First, we noticed issues with the smart pump within a specific patient room. These problems were initially attributed to interoperability noncompliance. After further research, we identified that the room was not receiving the WiFi signal well, which we were able to troubleshoot and resolve.

Quarterly, we complete high-level reviews of both hospital- and health system-wide reports from our smart pump vendor. This review includes examining the actual builds and validating items such as our alert limits and the safety software for the alerts. We also confirm that the alerts that are firing are appropriate and accurate. If alerts are trending high, we look to identify the cause, such as a recent policy change or the introduction of a new medication that may require a change to the drug library programming to support. We also look for any medications that present as an issue across the board that may require an interdisciplinary review.

Interdepartmental Collaboration

Q: What changes have you incorporated to help support nursing staff?

Augustino: Addressing nursing staff’s concerns and helping to ensure a smooth workflow for that department is a priority for our team. In order to facilitate this, pharmacy and nursing meet monthly to improve interoperability practices. One common target area is driving down incorrect, inappropriate nuisance alerts for nursing.

For example, sometimes at the end of the infusion or if a medication required titration, the calculations of the programmed rate did not match what was occurring on the floor. Getting that feedback and changing those alert limits helped to eliminate those nuisance alerts when the nurses are performing the infusion as prescribed.

Another change we have implemented is optimizing medication builds. As our familiarity with this technology improves, we recognized that the way that certain medications were built was a pain point for nursing. To address this, we expanded the number of rate range allowable medications to support titration, so that a new order is not required every time a rate change is needed. Feedback from practice truly helps to drive those changes on the pharmacy end.

For new nurses, we have a robust interoperability training program which includes practice cases. There is a practice environment for our health record and a practice environment for our pumps, so new nurses can experience practice scenarios that mirror what they will encounter on the floors. This practice environment is also available to any nurses who want extra training, to ensure that all of our staff are comfortable using the technology.

Q: What key features do you find are most useful for your staff?

Augustino: Building out standard concentrations has proved vital our staff. While interoperability and auto-programming are helpful, whenever there is downtime, we focus on having those concentrations built out to help circumvent forced reliance on manual programming.

Another key element is being judicious with our use of therapies. For a medication with multiple indications, we build out the available options for programming to ensure that the limits are appropriate for the given indications. Previously, we could not break out the builds to such a detailed level, which led to additional alert fatigue and negatively impacted safety.

We now have an enhanced ability to prevent nuisance alerts with the standard administrations. We also spent a lot of time rethinking our library design, where we would direct certain infusions, and how we would build it out to make sure it was clear which option should be used for what type of therapy.

Optimization Tips

Q: What tools did you find useful for optimizing the drug library?

Augustino: Successful optimization begins prior to launching interoperability technology. We began by examining quarterly reports and recording where the alerts occur most frequently in the current state. This practice served as an indicator of discrepancies between current practice at the bedside versus the drug library design. Next, we went through our policies and clinical guidelines in order to modify dosing recommendations, ensuring clinical infusion guidelines matched the dosing limits. We then divided the remaining discrepancies by clinical subsection and sent a list to the appropriate clinical pharmacy teams to review. This approach proved beneficial in the long run, as the clinical teams provided unique insight specific to their relevant experience. The nursing department especially felt the use of smart pumps with interoperability helped to streamline their processes.

Another optimization effort was provided by our IT team, who ensured that the builds were standardized across the institution. We now have a shared drug library and a shared build across multiple hospitals. Committing to using the same orders across the board initially required a significant effort, but getting everyone on the same page initially proved beneficial in the long-term.

Q: What are some of the common errors that arise, and how do you address them?

Augustino: One of the most common difficulties we have encountered is the issue of WiFi connectivity. There have been occasions where the pump cannot reach the WiFi, resulting in the signals failing to cross. To address this issue, we developed a tip sheet to help our nurses troubleshoot the situation. Usually, a solution can be found by either restarting the pump or relocating it. However, if neither of those options work, the tip sheet also includes information on where to place a ticket for the facilities department in order to evaluate if the area is a WiFi dead spot. All of the tip sheets are stored online on a shared site that can be accessed from our intranet homepage. The tip sheets are comprehensive in that they direct both troubleshooting steps as well as who to contact or where to place the ticket if additional assistance is required.

Q: Do you have any other advice for maximizing the potential of smart pump use?

Augustino: Generally, facilities focus their time and efforts on the initial launch of a program. However, a successful integration requires equal attention to ensure that level of performance is maintained through many years of interoperability. While there may be pressure to build the medication library as quickly as possible, care is needed to ensure the longevity of the technology.

One of the first steps was to establish a process for building a medication onto the electronic health record (EHR) while excluding it from the interoperability list. There are some medications in the ambulatory space that must be built in this way from a billing perspective, or because the timing of adding the medication is too far away from a pump update cycle; nevertheless, we want to ensure the patients are receiving the care they need. Establishing this middle ground option early on prevents nurses from being prompted to do something that they cannot or should not do, and it keeps the unit from being cited for inappropriate compliance. We also label these medications “this must be manually programmed” to signify to the nursing staff before infusion that the medication will need to be manually programmed on the pump using either a nonformulary entry or our standard for medications that have not yet been built.

Another helpful process was implementing a quarterly smart pump update schedule. This allows the nursing staff to plan and accommodate for each update. From the IT perspective, a set schedule allows us to focus on the builds that need interoperability integration on a quarterly basis. This approach is key to ensuring that the medications ordered in the EHR can be infused via the interoperability program.

We also adhere to this quarterly schedule for testing all new builds. For each new build, we conduct the same test as when we were preparing for the interoperability go-live to make sure that the new medication records function with interoperability system before they are set live on both the EHR and the pump. This test begins with the drug librarian creating a draft library on a test system a couple of weeks before the library is set to go live. The analysts then push their new build to the test system, and we run the interoperability to make sure that everything works and translates as expected. If any errors are revealed, we can troubleshoot and fix them before they impact patient care. This robust testing approach ensures that mistakes do not slip into the live environment.

Melissa Augustino, PharmD, BCPS, is the medication safety clinical pharmacy specialist at the Hospital of the University of Pennsylvania in Philadelphia, Pennsylvania. She received her doctor of pharmacy degree from the University of Maryland School of Pharmacy and completed her PGY-1 pharmacy practice residency at Howard County General Hospital. Dr. Augustino also completed a PGY-2 in medication-use safety at the Johns Hopkins Hospital in Baltimore, Maryland.