Closing the medication safety loop: when it comes to automated medication administration, reliable wireless connectivity plays a critical role in fully integrated environments.Mirroring the focus of the overall industry, St. Clair Hospital (St. Clair) has dedicated its efforts to ensuring patient safety. The hospital has had bar code point-of-care (BPOC) installed since March 2004, but wanted to further close the loop on medication administration. As such, in April 2007, St. Clair created an interdisciplinary team comprised of nursing, pharmacy, risk management, bio-med, IT and materials management to evaluate how smart infusion technology could further reduce the risk of medication administration errors. In addition, the team would make sure that any new technology would align with existing patient care processes that ensure the "seven rights" of medication administration (e.g., right patient, right medication, right dose, right time, right route, right reason and right documentation).
After 12 months evaluating smart pump technology, wireless connectivity, and associated reporting and management systems, the team deployed Hospira Symbiq smart infusion pumps to reduce the risk of infusion-related medication errors. Within 48 hours of use, reports indicated several incidents where an attempt to program the smart pump at a rate exceeding established limits triggered a "hard stop" and, thus, prevented the error from harming the patient.
The smart pump technology had fulfilled its promise, yet many questions remained. Why did the nurse attempt to program the pump at such a high rate in the first place? Which nurse made the programming mistake? Who was the patient? Should a clinician check the electronic medication administration record (eMAR) or the input and output flowsheet (I&O) for this patient? Does the attending nurse need additional training on dosing calculations?
Unfortunately, these valid questions could not be answered using the standard reports. To address these outstanding medication safety gaps, complete integration between the Symbiq smart infusion pumps and the Hospira VeriScan BPOC system would need to be accomplished.
Addressing the Technology Gap
In a typical month at St. Clair, up to 3.4 percent of all infusion orders generate some type of alert on the pump. Roughly half of those alerts result in the nurse overriding the alert (e.g. soft limit alerts) and then proceeding with the programmed rate. The other half of those alerts (e.g. hard limit alerts) require the nurse to edit the programmed rate before the infusion can be started. It is certainly not necessary for nursing management, or the risk management team to follow up on all of these records; however, in certain situations, an investigation is warranted.
Conducting the research, however, can be difficult due to the pump not being "patient-aware" or "caregiver-aware." Integrating the smart pumps and the BPOC system solves this problem. Integration provides the proper association between patient, pump, caregiver, physician order and medication so that a full audit trail is available.
Despite the obvious need for integration, there are challenges to overcome before the medication administration loop is closed. For example, the workflows associated with oral medications and infusion medications are quite different. To enable the BPOC system to be used on every infusion, the workflow has to accommodate both the continuous nature of the infusion and the one-time event of the oral medication. This can be achieved by optimizing the workflow to become truly functional and intuitive for the nurse. At St. Clair, the infusion pathways are equally as convenient as the oral pathways and even include functionality to handle STAT orders and verbal orders.
Another challenge in using the BPOC system for infusion administration is ensuring the proximity of the BPOC device to the smart pump so that they can work together. With its small mobile form factor, a PDA-based BPOC device can be easily located close to the pump, but this process can become challenging if a COW (computer on wheels) is used in place of a smaller mobile device.
Once the challenges are overcome, the benefits of integration are substantial. As the nurse performs the aforementioned seven rights of medication administration while starting the infusion, the patient's and nurse's identities are recorded by the pump server. As part of the integration, the BPOC system quickly identifies the nurse, patient and pump used in each intravenous (IV) administration. Standard reports that previously showed only infusion data are now able to show that same information within the context of the patient and caregiver.
Another benefit of the smart pump and BPOC system integration is "pump auto-programming." This capability eliminates an elusive patient safety gap. In an environment without auto-programming, the nurse must manually select the medication from a list of choices on the pump. If the nurse accidentally selects the wrong medication, the pump will proceed as programmed with the wrong infusion limits. Within an integrated environment, the BPOC application utilizes the wireless LAN capabilities of the VeriScan PDA and sends the medication selection electronically to the smart infusion pump. An extension of the seven rights verification, the process ensures that the correct medication is selected and the appropriate rate limits are activated; thus, removing the potential for human error.
Other benefits include improved quality of reports for management and improved patient safety. With any implementation of new technology, there must be a tangible value delivered to the user, which, in this case, is the nurse. The value-add comes in the form of auto-documentation. When the nurse completes the administration on the BPOC device, the administration is automatically charted to the eMAR, eliminating a separate, manual documentation task. Likewise, since the BPOC system and the smart infusion pump system are integrated, the infusion data that has been collected on the pump server can be supplemented with the patient context and used to chart the intake volume on the I&O flowsheet. This automation delivers tremendous time savings for nurses, as well as improved data accuracy since the pump is monitoring the volume infused rather than being derived from manual calculations.
The nurse also gains easy access to the full details of each patient's pump status and infusion status via the PDA. If nurses hear a pump alarming in a room at the far end of the unit, they can use the PDA to retrieve the status of all pumps on the nursing unit. This allows them to quickly determine who is responsible for responding to the alarm and initiate the appropriate reaction. From anywhere on the unit, they can view the pump status on their PDA and verify whether the pump is running; if it's in alarm status; how much volume has been infused and what volume remains. This increased productivity allows nurses to allocate the saved hours to further improving patient care.
Devil is in the Details
As a hospital transitions from a non-integrated environment to a fully integrated environment with a BPOC system and smart pumps, it is important to have strategies in place for managing the size of the drug library stored in the pumps. In a non-integrated environment, the nurse manually selects the medications from a pick list on the front panel of the pumps. Therefore, the list must be a manageable size to avoid scrolling through dozens of screens to find the desired medications.
However, in an integrated environment, the physician electronically orders the exact medications using a PDA, and drawing on an extensive drug library to match all the possible combinations of the order-entry system. In the non-integrated environment, the rudimentary library is a necessity, and in the integrated environment the detailed library is mandatory. The pharmacist in charge of creating and managing libraries can facilitate this migration by utilizing library versioning conventions and clinical care area naming conventions.
Before rolling out the pilot installation, it is extremely important to verify the operation of the wireless LAN. In a non-integrated environment, the smart pumps only need to participate on the network for occasional drug library updates and tasks associated with batching infusion data to the server. However, once integration is achieved, the wireless BPOC device will transmit the medication to the pump for each and every infusion.
Additionally, the pump will need to send real-time data on the status of the infusion to the server to keep dashboards constantly updated. Both of these capabilities necessitate reliable wireless connectivity for both the PDA and the smart pumps. To ensure that St. Clair maintained strong connectivity, technicians examined all the nursing units and tested every location where the wireless devices would be used.
Many patient safety initiatives within hospitals result in soft-dollar ROI. In other words, patient safety improves, but the cost of error avoidance cannot be measured objectively. However, in this case, integration of BPOC and smart pumps can provide a hard-dollar ROI. In an environment where a BPOC system is not installed, or not utilized with infusion medications, it is impractical to record the start and stop time of each IV and each bag within the overall therapy. However, with an integrated system, infusion therapy start and stop times are electronically recorded. This information can then be used to increase reimbursement.
Pre-integration, with BPOC alone, St. Clair Hospital has already achieved an average of $10,500/month in incremental reimbursement on O/P infusion therapy. This is due solely to obtaining accurate information on the IV therapy and leveraging that data for reimbursement. Now, with integration between the BPOC system and the smart pumps, reimbursement is expected to double, as a greater percentage of the infusions will have a verified and recorded completion time.
The integrated environment brings together two key data elements: bag changes and the related times. Nurses always know that a bag change is taking place; however, they may not know when the previous bag was completed. With the combination of BPOC and smart pumps, nurses can indicate that a bag is being changed, and the pump server provides the specific time that the previous bag was completed. This combination produces accurate billing and enables the hospital to maximize reimbursements.
For St. Clair Hospital, the integration of smart pumps and BPOC superseded expectations with reduced medication administration errors; improved patient safety; enhanced clinician productivity; expanded reporting to include patient context; and, the healthcare Holy Grail, tangible ROI.
Richard Schaeffer is vice president and chief information officer, St. Clair Hospital, Pittsburgh. Contact him at Richard. Schaeffer@stclair. org.