By Stephen F. Eckel, PharmD, MHA, BCPS

At the University of North Carolina Hospital (UNCH), a 726-bed tertiary care hospital located in Chapel Hill, the pharmacy department implemented smart pumps about five years ago. We began with a two-week beta test of the smart pump system in a 16-bed intensive care unit; the documented safety net provided by the drug library during this short trial drove our decision to adopt these IV pumps facility-wide. Since that time, we also have implemented smart PCA and pediatric syringe pumps, and we will soon implement smart epidural pumps.
Some key lessons we have learned over the past five years are as follows:

• Education must be continuous: Given the turnover and addition of new nurses, it is essential to educate staff on how to use the drug library, when to use it, and what it contains. While many organizations complete this task at the outset, a structure for ongoing education needs to be developed. Our organization has integrated pump education and smart pump teaching into our new nurse orientation and the contents of the drug library are on our Web site for anyone to review.
• Understand the role of the Pharmacy & Therapeutics (P&T) Committee: We asked the P&T Committee to approve our first drug library. Because the implementation of smart pumps required us to standardize all concentrations, and since the P&T Committee approve all of our clinical guidelines, it was a natural extension to have them continue to approve all library changes. Over time, this approach has turned out to be strategically sound. When a physician group recommends a change to a concentration or a dosing unit, these requests often conflict with what other physicians have requested. To avoid putting the pharmacy department (or a single pharmacist) in the middle of these issues, the P&T Committee works with the physicians to make the best decision for the organization.
  
• Include all medications in the drug library: In order to simplify the process for our nursing staff, we have attempted to load all medications or therapeutic classes (IV fluids, antibiotics, chemotherapy, etc.) in the pump. Our goal is to simplify the process for the nurse programming the pump. Rather than wondering whether a specific drug is in the library, the nurse has everything they need in the library. This enables easier compliance with drug library use, and there is no need to provide instruction on programming the pump without using the drug library.

Solving Some Issues, Creating More
While these lessons learned helped us increase the adoption and use of the smart pumps, there were still issues remaining that we needed to overcome. For example, when a drug library required updating, we had to individually handle every single pump, using a hard-wire connection to upload the drug library. With over 1,000 pumps in our organization, significant manpower was required to successfully accomplish this task. Given the level of inconvenience, we averaged only one drug library change every 18 months, a process that also required significant support from the vendor. Taking this episodic approach to drug library updating created tension with our organization’s formulary decision-making process. There were times when we decided not to change to a more cost-effective medication because we could not accommodate the manual update to the drug library. Other times, we knowingly made a decision to add or change a medication, recognizing that it would not be entered into the drug library for the same reason.

Extracting utilization data—another manual process—also was difficult. When nursing leadership requested data on compliance or on how certain medications were being used, we could not provide real-time data. We downloaded all data on the pumps when the drug libraries were updated, but it was not real-time, and some data was lost due to the infrequent updates and the limited data storage capacity on the pumps themselves. By taking a manual approach, our organization could not fully maximize the benefits of the technology, furthermore, we could not effectively use our data to change practice and then measure the impact of the change in a timely way.

Resolving Inefficiency Wirelessly
Our organization determined that wireless connectivity to the pumps would be necessary to overcome these obstacles. A wireless pump is in constant communication with a server, whereby real-time utilization data is compiled in a database. Various reports can be run from the database, incorporating both historical and current data. Analysis of recent changes and their impact can be done in real-time, allowing the organization to track its success.

A wireless interface also allows us to push changes to the drug library whenever we want. Without the wireless feature, a change to the formulary might not be made due to the inability, or infeasibility, of updating the drug library; or the change might be made with the staff simply accepting that the drug library will be incorrect until an update is time- or cost-feasible. With the wireless feature, an organization can take full advantage of the cost savings often attendant to formulary change, keep the drug library current, and have access to user data at
any time.

Working with Administration
The above advantages were those we shared with hospital administration to justify the cost of upgrading our pumps to wireless as essential. In addition, there was overwhelming support from pharmacy, nursing, materials management, and biomedical engineering to make this change. The combination of staff support and tangible practice benefits indicated a priority for this technology in the budgeting process, and the money was set aside for the upgrade.

The Future of Wireless Smart Pumps
When considering the future of wireless smart pump technology, I envision the ability to perform auto-programming, whereby an order is entered into the pharmacy information system and immediately appears on the pump for that specific patient. The nurse would then scan the IV bag to provide a verification process. However, this would require the pump to be linked to a patient, which is currently not the case. Another benefit of this compatibility could be the inclusion of a mechanism that would determine how much fluid remains in the bag. Instead of pharmacy receiving a call from the nurse for a new bag, the pharmacy could predict when the bag is almost empty and send a replacement in advance of the call.

While such functionality is still theoretical, we can take advantage of the existing benefits of wireless technology today. At UNCH completing the move to wireless smart pump technology has not been a process without challenges and lessons learned along the way. However, having a basic understanding of the concepts discussed here can ease your organization’s transition to enhanced smart pump technology.

Stephen F. Eckel, PharmD, MHA, BCPS, received both his BS and doctor of pharmacy from the University of North Carolina at Chapel Hill. Following a pharmacy practice residency at Duke University Medical Center, he began as a clinical pharmacist at the University of North Carolina Hospitals. He also completed a masters of health care admin­istration from the UNC School of Public Health. Stephen is an assistant director of pharmacy and is residency program director for UNC Hospitals. He is responsible for managing all adult, pediatric, and ambulatory clinical services. He is also director of graduate studies in the division of pharmacy practice and experiential education at the University of North Carolina, Eshelman School of Pharmacy and heads the masters of science in hospital pharmacy administration program. Stephen is board certified as a pharmacotherapy specialist.

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