bellinda johnson & maureen heywood, st. vincent’s health network: does one dataset suit all:...

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

25th March 2013 Smart infusion pump technology in an EMM enabled hospital

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


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.

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, nanogramweight-based BSA-basedconcentrations

PCA specific doses / boluses

CQI – Continuous Quality Improvement tool for reporting records any breaching of limits- Nurse education- Dataset improvement



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


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 andPharmacist 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

Timeline

Jun 10

Mater go-live

Jun 11

Private dataset

build

Sept 11

Private go-live

78 drugs / 5 fluids

Nov 11 Public datasetbuild

Feb 12 Public go-live

155 drugs /

32 fluids

May12 Private

CQI

Nov 12 Private updated Dataset

139 drugs /

39 fluids

Mar 13 Public CQI

report

Mar 13 Public

Dataset

183 drugs / 32 fluids



Challenges (1)

1. Vendor contract – signed before implementation teams in place -worked backwards from end date to extremely tight deadlines

2. Almost nil implementation resources allocated

3. 20 character drug name limit

4. Drugs and fluids are separate

5. Rounding / Weaning doses

6. Physical weight of pump – adapt process of patient transfer

1. No ability to stretch timelines meant decisions HAD to be made and acted upon immediately – no SHOWSTOPPERS allowed!

2. SVPH had 0.2FTE data entry nurseSVH pulled 1.5FTE Pcists from eMMSand ward workAll nursing, medical and senior pharmacist review / signoff at both sites squeezed on top of daily duties

3. ACSQHC recommendations for no abbreviations and use of “mcg” impossible to adhere to in a number of circumstances


Challenges (2) - but collaboration ensured outcomes

PRIVATEDid 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 wirelessmaintenance program

Identified policies needing change

PUBLICHow 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

Solved some of the tricky drugs

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


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)


Challenging high-risk drugs

Tirofiban

This

translates to

This


What to consider with eMMS(MedChart®) and Alaris® pumps


Compliance Audits - results

Private Dec 2011

PrivateAug 2012

Private Diff

Public Apr 2012

Public Oct 2012

Public Diff

PCU correctprofile

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% -


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 NoradrenalinePropofolMaintenanceSod NitroprussideGlyceryl trinitrate

NoradrenalinePropofol – continuousMidazolamPropofol - bolusMorphine(+Midazolam)



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


Drug not in my pump – was yesterday!Where is MY pump?

Image caption here


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

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

Dataset

Private Public

Dataset 5 profiles crit caremedsurgcard medsurgOncologytraining

4 profiles crit caregeneralhem_oncologytraining

Trust Pharmacist updates only private ?Governance

Pharmacist updates only public

??? Agree -Rx Agree - Rx &EMM

Review When

CQI reports annually Ongoing-


If you have a resource you can rapidly respond


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 21 drugs (26 changes)

Concentrations 5

Name changes or advisory addition

8

Improved compliance

Improved patient safety

Discussion; of Public having ability to provide updates

Set and Forget??

If you create an entry in the smartpump must also do in eMMS - resource must be trained in both

bellinda johnson & maureen heywood, st. vincent’s health network: does one dataset suit all:...

Health & Medicine

private updated dataset

demands smart pump initiation

private dataset build25th

public datasetnov

public try

public ones

clinical error error

pharmacist input nurse