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Bellinda Johnson & Maureen Heywood, St. Vincent’s Health Network: Does One Dataset Suit All: Smart Infusion Pump Implementation In An EMM-Enabled Hospital

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Belinda Johnston, Director of Pharmacy Services and Maureen Heywood , Clinical Information Systems Pharmacist Pharmacy Dept., St. Vincent’s Health Network, NSW delivered this presentation at the 2013 …

Belinda Johnston, Director of Pharmacy Services and Maureen Heywood , Clinical Information Systems Pharmacist Pharmacy Dept., St. Vincent’s Health Network, NSW delivered this presentation at the 2013 Electronic Medication Management conference. It is Australia’s only conference to look solely at electronic prescribing and electronic medication management systems. For more information on the annual event, please visit the conference website: http://www.healthcareconferences.com.au/emedmanagement

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  • 1. Does one dataset suit all? Smart infusion pump implementation in a cross-campus collaboration 2nd Annual EMM Conference 25 March 2013 Belinda Johnston: Dir. of Pharmacy, St Vincent’s Private Hospital Maureen Heywood: eMedicines Management Pharmacist ,St Vincent’s Public Hospital
  • 2. Why New Pumps? Old pumps dying - no longer supported with service or parts Increasing patient acuity and shorter lengths of stay required adequate equipment to meet demands SMART Pump initiation a recommendation of CEC MSSA (Medication Safety Self Assessment) – SVH and SVPH 2011 SVMHS ITSC infrastructure supports use of wireless technology Fits SVMHS campus e-medicines vision Reporting and Continuous Quality Improvement capability 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 2
  • 3. Are IV Meds infused safely? - Evidence •Prof J Westbrook et al administration errors study¹ • Nearly 70% of all intravenous medication administered had at least one clinical error and 25.5% of these were serious. • Wrong rate was the most frequent error type • UK and German observational studies suggest 49% and 48% overall error rates •Prof J Westbrook et al interruptions study² •Nurse experience level provided no protection against making a clinical error •Error severity increased with interruption frequency •Wrong IV administration rate was the second most frequent clinical error with 35.7% of these errors rated as being of major severity 1. Westbrook JL, Rob MI, Woods A, Parry D. Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Qual Saf 2011;20:1027-1034 2. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010 Apr 26;170(8):683-90. 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 3
  • 4. What is a SMART PUMP? (1) Dose error reduction software Guardrails® Locally defined drug dataset of meds, IV fluids and blood products Sophisticated dose / rate / concentration expressions: g, mg, mcg, nanogram weight-based BSA-based concentrations PCA specific doses / boluses CQI – Continuous Quality Improvement tool for reporting records any breaching of limits - Nurse education - Dataset improvement 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 4
  • 5. What is a SMART PUMP? (2) Each hospital defines “clinical area” Profiles Each profile is populated with appropriate drugs in a library where doses, concentrations, rates, soft and hard min/max limits are coded Advisories Therapies 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 5
  • 6. Cross campus private / public collaboration The Mater SV Private SV Public Beds 216 270 350 Medication charts Paper Paper Electronic MedChart® Prescribers VMO VMO JMO Drug Protocols Own + similar Similar (co-located) Similar (co-located) Initial dataset From scratch From Mater From Private Implementation Date June 2010 Sept 2011 Feb 2012 Dataset Team Nurse led; VMO and Pharmacist input; Nurse and Exec sign-off Nurse led; VMO input; Pharmacist and Exec sign-off Pharmacist and nurse led; MO input; Pharmacist and Exec sign-off Dataset Development 16 weeks 16 weeks 16 weeks Number of Brains / Modules / PCA 85 / 100 / ? 150 / 220 / 60 270 / 450 / 25 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 6
  • 7. Timeline Sept 11 Private go-live 78 drugs / 5 fluids Jun 10 Mater golive Jun 11 Private dataset build 25th March 2013 Feb 12 Public go-live 155 drugs / 32 fluids Nov 11 Public dataset Nov 12 Private updated Dataset 139 drugs / 39 fluids May12 Private CQI build Smart infusion pump technology in an EMM enabled hospital Mar 13 Public Dataset 183 drugs / 32 fluids Mar 13 Public CQI report Page 7
  • 8. Challenges (1) 1. Vendor contract – signed before implementation teams in place worked backwards from end date to extremely tight deadlines 1. No ability to stretch timelines meant decisions HAD to be made and acted upon immediately – no SHOWSTOPPERS allowed! 2. Almost nil implementation resources 2. SVPH had 0.2FTE data entry nurse allocated SVH pulled 1.5FTE Pcists from eMMS and ward work All nursing, medical and senior pharmacist review / signoff at both sites squeezed on top of daily duties 3. 20 character drug name limit 4. Drugs and fluids are separate 3. ACSQHC recommendations for no abbreviations and use of “mcg” impossible to adhere to in a number of circumstances 5. Rounding / Weaning doses 6. Physical weight of pump – adapt process of patient transfer 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 8
  • 9. Challenges (2) - but collaboration ensured outcomes PRIVATE Did not attempt to create a complete drug library due to timelines – knew public was about to start its implementation so mutual agreement to let public try and sort the tricky drugs NO dataset updates whilst public was developing theirs Tested wireless connectivity Biomedical engineering input: configured wireless maintenance program PUBLIC How to NOT corrupt / edit / delete private profiles whilst adding public ones on the same dataset – lots of trust, strict rules. Constant consultation with private ensured needs of both managed (eg: profile names changed to allow easy identification of private vs public) Haematology / Oncology profile a must have – hardest – varied dose ranges – good outcome was public could be copied to private Aimed for shared Critical Care profile but due to different PCA’s had to have separate Identified policies needing change Solved some of the tricky drugs 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 9
  • 10. Incredible Feedback SVH learned from SVPH and adopted tactics: 1. Staff Engagement • Outstanding involvement by Clinical Nurse Educators • Rallied their nursing colleagues • Pro-active responses and “gathering of info” • Engaged medical input 2. Ward feedback books idea • SVPH - QA senior – visited the wards collecting data requests • SVH – Clinical Resource Unit Snr Nurse walked wards and collected A4 feedback forms 3. Staff encouraged to actively contact dataset team 4. Monthly meetings 5. Alaris® vendor (Carefusion) feedback sought 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 10
  • 11. FIRSTS! SVPH - First wireless pump implementation in Australia (Sept 11) Second multi-site dataset BUT first multi-site dataset where the 2 hospitals had their own and separate profiles all on the same dataset (Private has 5 / Public has 4) 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 11
  • 12. Challenging high-risk drugs Tirofiban This translates to This 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 12
  • 13. What to consider with eMMS (MedChart®) and Alaris® pumps 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 13
  • 14. Compliance Audits - results Private Dec 2011 Private Aug 2012 Private Diff Public Apr 2012 Public Oct 2012 Public Diff PCU correct profile 88% 88% - 90% 96% 6% Patient ID 0% 0% - 52% 42% 10% IV Fluids via Guardrails 72% 51% 21% 90% 86% 4% IV Fluids avail in dataset 100% 100% - 100% 100% - IV Drugs via Guardrails 88% 67% 21% 95% 94% 1% IV Drugs avail in dataset 88% 93% 5% 100% 100% - 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 14
  • 15. Alaris® Infusion Analytics Review CQI Private Public Severe harm averted (potential ADE’s) 29 205 Potential cost saving $254,000 $1.79 million Total good catches 20 142 Total override alerts 5490 9528 Top 5 overrides 25th March 2013 Noradrenaline Propofol Maintenance Sod Nitroprusside Glyceryl trinitrate Smart infusion pump technology in an EMM enabled hospital Noradrenaline Propofol – continuous Midazolam Propofol - bolus Morphine(+Midazolam) Page 15
  • 16. Issues requiring immediate action Wireless- blackspots in HOAC- for the initial 3 uploads had to move pumps out into corridor for dataset to upload Windows 7 PC upgrade – Alaris® incompatible – still awaiting patch (had to keep an old version PC in XP) Power boards in pumps had to be replaced due to international recall – took weeks / months 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 16
  • 17. Drug not in my pump – was yesterday! Where is MY pump? Image caption here 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 17
  • 18. The FUTURE Aligning MedChart® complex infusion orders with Alaris® “smartpump” drug library Further collaboration on possible amalgamation of profiles for SVH and SVPH dataset (eg: critical care) ??does one dataset work to include Mater and St Joseph’s Future electronic interfaces (eMMS to infusion pumps) Disaster Plan and Recovery Testing 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 18
  • 19. Thank You Does one dataset suit all? Smart infusion pump implementation in a cross-campus collaboration 2nd Annual EMM Conference 25 March 2013 Belinda Johnston: Dir. of Pharmacy, St Vincent’s Private Hospital Maureen Heywood: eMedicines Management Pharmacist ,St Vincent’s Public Hospital
  • 20. Dataset Private Public 5 profiles 4 profiles crit care medsurg card medsurg Oncology training crit care general hem_oncology training Trust Pharmacist updates only private ?Governance Pharmacist updates only public ??? Agree -Rx Agree - Rx &EMM Review When CQI reports annually Ongoing- Dataset 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 20
  • 21. If you have a resource you can rapidly respond Improved compliance Discussion; of Public having ability to provide updates PUBLIC First x…?? months Dataset wireless updates ~ 2 weekly – how many b/w golive and now New drugs added 28 (8 in 1st week) Limits changed Improved patient safety 21 drugs (26 changes) Concentrations 5 Name changes or advisory addition 8 Set and Forget?? If you create an entry in the smartpump must also do in eMMS - resource must be trained in both 25th March 2013 Smart infusion pump technology in an EMM enabled hospital Page 21