Chicago, plays a key role in the ordering, dispensing, administration, and monitoring of medications. Hospital pharmacy, in collaboration with medical and nursing staff, routinely reviews and audits the entire medication-use system and has incorporated automation into the system to make it more efficient and safe.

Identifying Automation Needs
During a review of our medication-use process, we realized we had little automation dedicated to assisting our nurses at the point of drug administration. As research has shown, only 2% of the medication errors made at this step are intercepted, with 41% of the errors causing temporary or permanent harm or death to the patient. We recently had encountered some administration errors related to anticoagulants that would likely have been prevented if drug libraries were in place and used correctly.

To address this issue, UIMC released an RFI on smart pump systems and identified three vendors that fit our criteria. Each vendor was invited to demo its pump in-house to a multidisciplinary (nursing, pharmacy, and materials management) group for evaluation. In addition, calls were made to institutions currently using these pumps. The results were presented to our IV Pump Steering Committee along with overall cost information. The committee made the recommendation to purchase B. Braun’s Outlook 400ES system.

Building the Drug Library
We began the process of identifying and building the smart pump drug library by meeting with key stakeholders (nursing, pharmacy, and anesthesiology) four months before the proposed go-live date. We identified the clinical areas that would be using the pumps and clinical pharmacists were assigned to develop a draft drug library for each of these areas. Nursing and physician representatives from each clinical care area then reviewed the drafts. The clinical pharmacists used existing protocols and previously established standard concentrations for medications when possible. However, new protocols for PCA, epidurals, and peripheral nerve blocks were already under consideration and were developed along with the new infusion pumps. The initial draft of the drug library, covering 13 clinical care areas, took about six weeks to develop and involved 20 clinical pharmacists. The nursing and physician reviews, and subsequent updates took an additional four weeks.

Smart Pump Implementation
A project manager was appointed to coordinate the schedules of multiple departments (IT, clinical engineering, materials management, nursing, pharmacy, and anesthesiology) with the vendor’s rollout plan. In addition to building the drug library, critical pre-implementation functions included validating the compatibility of the pump’s wireless setup with our wireless network; setting up a new server (for reporting functionality) in our IT data center; key group review of our custom drug library and of the vendor’s disposables; and training for pharmacists, nurses, and anesthesiologists. For every single pump we needed to confirm the drug library was properly downloaded, and the connectivity with our reporting system was valid. This preparation culminated in the activation of each pump throughout the hospital, a process that took about 12 hours. Including our highly developed drug library and the new protocols and orders built into our EMR, we completed the entire implementation process in just four months.

UIMC is planning to begin using Outlook 400ES’s wireless capabilities once the software is available from the manufacturer. We have the necessary infrastructure in place to enable wireless communication between the smart pumps and the central server. In the meantime, pharmacy is planning a manual update of the drug library based on feedback collected from users and smart pump reports over an eight-week period that took place after the go-live. Future requests for changes to the library will be sent to a pharmacy representative for initial review. A compilation of the requests will then be sent to our Medication Systems Review Committee and Pharmacy and Therapeutics Committee for approval. It is anticipated that changes to the library will revolve around formulary medication changes and will occur quarterly.

Training and Challenges
We held training sessions for clinical pharmacists early on to help them understand what information would be required to build the drug library. As primary users of the pumps, we waited to train the nurses and anesthesiologists until one week prior to go-live date, to avoid a lengthy gap between training and actual use. Our training process included a formal presentation combined with hands-on demonstrations. It was difficult to train the different users on all aspects of the new pumps and the drug library in a concentrated time period. Additionally, changing to different disposables raised concerns, particularly in the OR. These issues arose during the drug library validation phase, and in retrospect should have been discussed during the early pump demonstrations.

Report Data and Practice Response
Of the reporting features available to us through the Outlook 400ES system, the DoseGuard alert report already has helped identify potential medication errors. This report also has helped identify potential changes needed to the minimum and maximum limits we have set up. While the report data we have gathered has yet to lead to any practice changes, we are evaluating the possibility of standardizing the dosing units in all care areas for vasopressor agents (e.g., mcg/min vs. mcg/kg/min for epinephrine and norepinephrine) and sedative medications (e.g., mcg/kg/hr vs. mcg/kg/min for fentanyl/midazolam infusions).

Staff Acceptance
The pharmacy staff was quick to embrace the potential safety advantages of the drug library. The drug library is quite comprehensive, containing 130 DoseGuard and 50 RateGuard items. The nursing staff was equally excited about the safety potential and are beginning to use the functionality more often as their familiarity and comfort with programming the pumps increases.

We conducted an audit three weeks after the go-live to determine if the drug library was being accessed and used appropriately. We sampled patients on non-ICU wards, as we had already observed near 100% compliance with use of the drug library in the ICU areas. Of the nearly 500 patients observed, we found that items were correctly selected from the DoseGuard or RateGuard library about 24% of the time. The top items being infused using the DoseGuard library were heparin, argatroban, esomeprazole, and nitroglycerin. We realized the biggest obstacle was ensuring the nursing staff knew which agents were available in the DoseGuard or RateGuard library. While that information was available on the medication label, it was being missed due to small font type or poor location on the label. Re-education on the drug library is planned as part of our nurses’ annual competency assessments.

Lessons Learned
There are a few important steps that should be stressed when considering such a system. Well before your go-live date, plan to establish the drug library and have as many stakeholders review the library as possible. Once you have begun the process of bringing the pumps on board, avoid introducing new drug protocols or medication administration practices at the same time. In addition, every pump brought into the hospital should be validated. Finally, do not underestimate the amount of time needed to train front-line staff. Not only do they need to learn how to operate a new infusion device, but also when to use the drug library and how to react to alerts related to the drug library. UIMC personnel working in areas where medications in the drug library are used commonly (e.g., critical care, OR) quickly adapted to looking for drugs in the library. Personnel working in areas where medications are not as commonly available in the library tended to forget to access the drug library. Ultimately, the entire process needs to be reviewed and understood at all phases of implementation in order to ensure proper patient safety.

John Garofalo, PharmD, is the associate director of clinical pharmacy services at the University of Illinois Medical Center (UIMC), and clinical assistant professor in the department of pharmacy practice at the University of Illinois at Chicago, College of Pharmacy. Dr. Garofalo obtained his doctor of pharmacy from the University of Illinois at Chicago and completed an ASHP accredited clinical pharmacy residency at the University of Illinois Hospital. His teaching interests include gastrointestinal disorders, fluid and electrolyte disorders, and nutritional support. Dr. Garofalo chairs the Medication Reconciliation and Glycemic Control Taskforce and serves on the Pharmacy and Therapeutics Committee at UIMC.

Digital Edition

PP&P is now available online in the exact layout and appearance of the print edition, and includes more interactive features, such as the ability to access websites and request information with the click of a mouse.  To view this article in the digital edition, CLICK HERE.