The process of preparing and administering IV medications was not as efficient or as safe as WellSpan Health wanted it to be back in 2009. There were many issues, but the crux of the problem was that pharmacy staff charged with IV infusion preparation had little control over the manual production process, and nurses had little to no insight into how pharmacy managed the medications.
That disconnect caused frequent disruptions in workflow, raised additional efficiency concerns, and perhaps most importantly raised the risk for drug administration errors, according to Chip Gerhart, RPh, the medication safety officer at WellSpan York Hospital, one of three facilities operated by York, Pa.-based WellSpan Health.
Mr. Gerhart and his colleagues didn’t waste much time in finding a solution to their infusion problems. In July 2010, following an earlier pilot launch, WellSpan says it became the first health system in the world to implement an integrated automated infusion management system, choosing infusion pumps that could connect with their patients’ electronic health record (EHR). Today, the system is in place in a coronary care unit, a trauma surgery ICU and a 60-bed step down area for cardiac patients, and covers a total of 90 beds.
Speaking during a webinar on the rollout presented on unSummitU.com, Mr. Gerhart and Sharon Muller, RN, MSN, the coordinator of nursing informatics at WellSpan Health, discussed the limitations of the hospital system’s
previous infusion devices and reported the benefits realized since the switch to an EHR-integrated model of infusion management.
Too Many Cooks in the Kitchen
Before the rollout, WellSpan relied on nurses, pharmacists and pharmacy technicians to produce its continuous infusions. Under that scenario, nurses, who are frequently very busy tending to the various needs of multiple patients, were required to monitor the status of titrated infusions and reorder the infusions from the pharmacy on an “as needed” basis. “In our ICU setting, the reorder process often broke down and we would receive frantic phone calls that the medications were running out in five minutes, or worse, had already run out and the medication was needed immediately,” Mr. Gerhart said. “That meant dropping everything to make and deliver the infusion to the ICU.”
Even when the process worked as expected, he added, “every reorder notification had to be handled by a pharmacist. The end result was a disruption to the workflows of both the pharmacist processing the reorder and the nurse tasked with sending the notification.”
The new integrated infusion management system, in contrast, uses a variety of connected technologies to create transparency surrounding the reorder process for both pharmacy and nursing. “We use Cerner’s infusion management product and Hospira’s Symbiq infusion devices and MedNet safety software,” Mr. Gerhart wrote in an email.
During the webinar, it was noted that these components “provide bidirectional, wireless communication between the smart pump and the electronic medical record, resulting in a closed-loop, integrated infusion management system.”
Bar-code scanning is another important cog—particularly in conjunction with the EHR, according to Ms. Muller. When a bar code is scanned, that action sends electronically captured information about the infused medication to the pump, and the pump sends information to the EHR. “Real-time volume titration data are streamed from the pump into the EHR for the clinician to see,” she explained, “allowing real-time analysis and documentation of clinical data.”
By sending data to the pump automatically, Ms. Muller added, “you avoid manual programming errors where a nurse taps the wrong key, so the safety benefit is huge. The real-time streaming data give you a situational awareness that allows you to make clinical decisions based on accurate, actionable information.”
Dashboard Guides Clinicians
The software within the infusion management system at WellSpan provides a “dashboard” view of infusion-related information to both pharmacy and nursing. This is done via a 50-inch monitor in the pharmacy’s IV anteroom area, where the software displays information on patient demographics, location, current medication order, current infusion rate, workflow sequence status and the time remaining before the infusion is complete. The data are displayed in columnar views that can be sorted according to what each user wants to prioritize.
In the pharmacy, technicians rather than pharmacists monitor the dashboard to determine what particular continuous infusions need to be prepared and delivered to the patient care area. “The pharmacy technicians have the insight into the process and they manage it independently rather than having pharmacists and nurses tied to that process,” Mr. Gerhart said. This approach is in stark contrast, he added, to the earlier system in place at WellSpan, where IV technicians were at the mercy of the IV printer that “spewed labels on an ongoing basis with little to no insight from the technician as to which orders took priority.”
Infusion stability is taken into account by the system as well. Certain standard-size infusion bags are tagged with a 24-hour expiration date via the pharmacy information system. When these infusions are administered at infusion rates that would result in the infusion exceeding its stability, the time remaining calculation is based on this expiration time instead of the actual time remaining for the bag, Mr. Gerhart said.
“That takes the guesswork out of it for nursing,” he added. “The delivery of a new bag to the [nursing area] is their indicator that they have to hang a new bag immediately.” Before the rollout, “we were forced to rely on nurses recognizing that a bag has hung for over 24 hours. Now, in contrast, we are minimizing the possibility of patients receiving suboptimal infusions that have outlived their stability.”
The older system was further hampered by another scheduling flaw: It resulted in the production of continuous infusions with standard, scheduled administration rates hours in advance of need. When orders were changed or discontinued in the interim between production and administration, these infusions had to be picked up and returned to the pharmacy, taking up a technician’s time and creating the potential for waste or possible errors if they were redistributed. In the new system, by not doing batch fills in advance of need, WellSpan is seeing “significant reductions in the volume of products coming back for credit,” Mr. Gerhart said. “We are not only realizing the cost savings for the drugs themselves, but also the savings in time for our technicians from not having to credit and destroy these products.” Moreover, returns and credits now automatically recalculate the time remaining in the dashboard, and the technicians also can see when an order has been modified or changed in any way, he noted.
Mr. Gerhart added that the flexibility of the workflow management component allows the pharmacy to assign different workflow sequences to each product should the pharmacy need additional pharmacist checks for high-risk medications. “Accountability and product tracking are further enhanced because the system records date, time and user information on each step,” he said.
Measures of Success
From July 2011 to January 2012, WellSpan documented 90 near-miss medication errors involved in the administration of IV infusions that were caught by the updated system, Ms. Muller noted. “We estimated cost savings of $77,000 for that time period and $132,000 annually for just the 10-bed ICU,” she said. “That calculation was based on 10% of the 90 errors reaching the patient and causing harm without the system in place.”
In addition, WellSpan calculated a 27% reduction in the time it took nurses to document the start of a new infusion and a 50% reduction in the time required to titrate an infusion and document that process. This equated to an estimated total of 1,300 nursing hours per year.
But numbers tell only part of the story. The nurses “have loved this [new system], especially in those critical situations where you don’t have orders and you are trying to write down vital signs and infusion information quickly, while focusing on taking care of the patient,” Ms. Muller said. “After the emergency is over and the patient is taken care of, the nurse can go back and pull all the data from the pump into the EHR. No more writing clinical data down on scraps of paper or on scrub pant legs.” (For more nursing benefits, see sidebar, “A Particular Boon to Nurses.”)
Mr. Gerhart added that the pharmacy technicians now have “a great amount of control over their workload, an opportunity they greatly appreciate.”
Hospitals that are eyeing an integrated infusion management system can learn some valuable lessons from WellSpan Health’s experience with the technology. Sharon Muller, RN, MSN, WellSpan’s coordinator of nursing informatics, said the following strategies helped ensure a successful rollout:
Begin with the right components—but not in isolation. Hospitals need to have bar-coding, smart pumps and an electronic health record system in place, and also have the ability to do order entry electronically, to get started on this type of initiative. “Each of those technologies [by itself] provides huge safety benefits,” Ms. Muller said. “But as you start to layer them onto each other, you see more and more increases in safety and efficiency.”
Ms. Muller described WellSpan’s decision to implement an integrated infusion management system as a “paradigm shift,” wherein many preconceived notions about pharmacy technology had to be discarded. One in particular: “We realized that a medical device can no longer be viewed as an isolated entity,” she said. “Its value increases dramatically when it is a component of the aggregate process. It has to be evaluated based on the data it can provide [to] clinicians.”
Be ready to work in teams. At WellSpan, Ms. Muller stressed, implementing the new integrated automated infusion management system was very complex, requiring partnerships among nurses, pharmacy, clinical and technical applications, bio-med, network and server support. “All of us had to learn to work and speak in ways we weren’t used to,” she said. “It was a huge learning curve.” Also, “there has to be transparency, commitment and communication” among all team members.
Start with high-need areas. At the beginning of a pilot implementation in 2009, WellSpan focused on “high-data volume, high-acuity areas,” Ms. Muller said, such as the ICU, the emergency department and the postanesthesia care unit. In those areas, WellSpan connected monitors, ventilators and anesthesia machines.
Be demanding of your devices. Before implementation, WellSpan evaluated infusion pumps three times, “not feeling at first that the pumps were at the level they needed to be for safety and integration,” Ms. Muller said. “But in 2009, we felt they were ready.”
There are several technology components in the new integrated infusion management system at WellsSpan Health. But the view of infusion status that can be gleaned from the infusion pumps may be one of the most welcome features to nurses, according to Sharon Muller, RN, MSN, the hospital system’s coordinator of nursing informatics.
Data displayed on the pump’s monitor show the order name, dose and rate, weight of the patient, volume to be infused, time to start infusion, and time remaining in “a continuous volume countdown,” Ms. Muller explained. In a typical use situation, the nurse verifies that all the information on the display is correct and that starts the pump’s two-way communication with the electronic health record.
“Once the data start flowing,” Ms. Muller said, “the clinicians can see the documentation in a number of different views, including an interactive view of all devices associated with the patient, including the pumps, monitors and ventilators.”
The pump displays a real-time view of “exactly what is infusing in a patient,” she further explained, as well as the status of an infusion and when it is going to be complete. “The nurse can quickly see what she needs to bring into the patient’s room, so if she is out at the desk, she can still see when she has to bring the next medication into the room.” The system also gives nurses a view of all the patients and their associated infusions on a unit level.
With the system and its various views, “the nurse is no longer the integrator of data,” Ms. Muller said. “She or he can let the pump send the data and she or he can then spend more time evaluating, synthesizing, looking at the data and focusing on it to see the full clinical picture.”
In addition to documenting what has been done in real time, with every titration the system displays for nurses a set of vital signs, and it graphs the data.
All these views and data points “simplify and streamline the IV medication process” for nursing, Ms. Muller said. As a result, the number of steps in the medication process “went from up to 42 down to seven when you program a weight-based medication. And, when you document what’s been done, the number of steps drop from 14 down to two.”
Additionally, in 97% of infusions, all the drugs being programmed are in the drug library on the pump, making optimal use of the pump’s safety software.
Chip Gerhart, RPh, the medication safety officer at WellSpan York Hospital, pointed to another major benefit of the workflow management system. Because it integrates with nursing views for each infusion, he explained, nurses gain insight into the production of each infusion, “eliminating the need for direct contact with pharmacy personnel altogether and minimizing disruptions to normal workflows for both groups.” This benefit alone has enhanced patient safety, Mr. Gerhart added, “because the safety literature demonstrates that distractions lead to errors.”