Management Advantage and Dis Advantage

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					           Wireless I.V. pumps allow for
           remote device management,
           monitoring of medication
           administration practices, prompt
           intervention of medication errors,
           and timely clinical education
           regarding near misses.
           By Linda Morgan, RN,
           and Lor Siv-Lee, PharmD
           ntravenous (I.V.) infusion pump technology has revo-

    I      lutionized administration of I.V. medication—many
           of which are high potency agents likely to cause
           injury if misused.1 Approximately 90% of hospital-
           ized patients receive I.V. medications, the majority
           delivered by infusion pumps.2 Although these
           devices have been responsible for improvements in
           the accuracy and continuity of I.V. drug delivery,
           they’re involved in 35 to 60% of the estimated 700,000
           adverse drug events (ADEs) occurring annually in
           the United States.1-3

20 February 2009 Nursing Management                       
   Morbidity due to ADEs is costly.
Each preventable event in the hos-       Table 1. Weighted evaluation tool for I.V. infusion pumps
pital setting is associated with an      Disposable requirements
additional estimated inpatient cost       1. Ease of priming tubing
of $8,750.4 Assuming the occurrence       2. Functionality of automated free flow prevention
of 175,000 in-hospital preventable        3. Ease of loading tubing
ADEs annually, the cost comes to          4. Easy to use I.V. set for gravity infusions
$15.3 billion.                            5. In an emergency, set can be removed quickly and safely from pump and set to
                                             gravity flow
   Medication errors can occur at         6. Ease of setting up secondary infusions (bag and syringe)
numerous steps in the process of          7. Ease of removing air bubbles
I.V. medication administration.5,6        8. Needle-free system was easy to use
Errors related to I.V. infusion pump      9. Product’s ability to ensure compliance (doesn’t allow direct use of needles)
programming have the greatest            10. Ability to prevent accidental disconnects (Luer-locking connections)
likelihood of causing patient harm.5     Technical specifications
Hence, interventions designed to          1. Ease of programming rate and VTBI (volume to be infused)
positively impact these errors            2. Ease of programming secondary infusions
should result in substantial reduc-       3. Ease of changing rate
                                          4. Ease of changing VTBI
tions in potential and actual patient
                                          5. Ease of clearing volume infused
harm and should receive priority.         6. Ease of utilizing numeric keypad
   A concerted effort to address I.V.     7. Ease of titrating both dose and rate
infusion pump-related errors has          8. Ease of switching back and forth from drug library to primary
led to the availability of a new gen-     9. Ease of activating and inactivating tamper resistance feature
                                         10. Ease of determining remaining battery power in real time
eration of I.V. infusion pumps,
                                         11. Ease of determining whether pump is on battery or AC power
known as “intelligent” infusion          12. Ease of changing from one drug library to another
pumps. These devices have the            13. Ease of reading display in all light conditions and from several angles
potential to prevent the majority        14. Easy to understand and act upon troubleshooting messages
of pump-related ADEs.7-12 The key        15. Ease of clearing nuisance air-in-line alarms
                                         16. Easy to adjust alarm tones
feature of intelligent pump tech-
                                         17. Ability of pump to assist in identifying I.V. site/I.V. line status
nology is software that permits          18. Ease of evaluating alarm/notification of miscalculated dose
the development of drug-specific         19. Ease of evaluating alarm/notification of hard and soft limits
libraries or rule sets, which include    20. Ability to override hard and soft limits
drug dosing parameters specific to       Physical dimensions
a given clinical care area (CCA) or      1. Ease of transport with regard to weight and flexibility of clamp
defined patient population. The          2. Actual size of pump
programmer is alerted if institution-    3. Adaptable to current patient environment
defined dosing parameters (such as       Overall infusion pump rating
dose, rate, concentration) are out-
side of preestablished limits.3
   These devices also have free-flow    quality improvement (CQI) infor-                tives from the nursing, pharmacy,
protection to guard against uninten-    mation.12 When used in conjunction              and biomedical engineering depart-
tional overdelivery of I.V. solutions   with wireless technology, data                  ments to rate each brand of infusion
or medications.13 When these            review and intervention can occur               pump. Criteria evaluated included
devices are used in conjunction         in real time.                                   the physical dimensions, technical
with bar-code technology and stan-                                                      specifications, disposable require-
dardized infusion concentrations,       Devise selection, implementation                ments (I.V. solutions, I.V. adminis-
they support the five “rights” of       Erlanger Health System (EHS) is a               tration sets), ease of programming
safe medication administration          tertiary care, not-for-profit, academic         (primary and secondary infusions),
(“right” drug to the “right” patient    facility affiliated with the Univer-            ease of changing programming
by the “right” route in the “right”     sity of Tennessee College of Medi-              parameters, and ability to resolve
dose at the “right” time).13,14 These   cine. Staff at EHS includes 999 RNs             alarm conditions. (See Table 1.)
devices also log data continuously,     and 124 LPNs. A weighted evalua-                   Input was aggregated into six
providing valuable continuous           tion tool was created by representa-            response fields: cost, disposable                                                           Nursing Management February 2009 21
Intelligent infusion

requirements, physical dimensions,             pump was initially assigned to a             being in alphabetical order. Hard
technical specifications, patient              patient, the CCA had to be desig-            and soft dosing limits were estab-
safety, and service. The respective            nated at that time. If the patient was       lished primarily using data provided
weights of the six fields were 20%,            transferred to another location, the         by drug manufacturers as well as
15%, 10%, 25%, 15%, and 15%.                   CCA would be changed by the nurse            input from clinical specialists based
Weighed scores were then averaged              accepting the transfer to reflect the        on their areas of clinical expertise
to provide overall scores used to              new location of the patient or level         and experiences delivering these
select the top device.                         of care that the patient required.           medications to patients. It was chal-
   Draft drug libraries were devel-               Preparation of the drug libraries         lenging to set limits for every drug
oped principally by a clinical phar-           involved searching and collating the         since dosing variations are common
macy specialist in May 2004 to help            institution’s existing I.V. preparation      in clinical practice.
streamline implementation once                 guidelines, policies, and procedures            The software program administra-
contractual arrangements had been              governing medication administra-             tor’s responsibilities included man-
finalized. The safety software can             tion (nursing and unit/patient popu-         aging drug library updates, device
incorporate data for a total of 18             lation specific), and standing order/        software upgrades, and data down-
CCAs. Staff nurses from various                electrolyte replacement protocols.           loads. This position was shared by
patient care areas were invited to             Preliminary drafts were organized            individuals in biomedical engineer-
provide input into the development             by generic names in alphabetical             ing, clinical pharmacy, and nursing,
of the draft drug libraries. The               order. Upon review, nurse managers           all of whom had upper management
committee felt that tailoring drug             requested a change to listing by             positions and vested interests in
libraries to specific patient care             brand names in most cases. The               the functionality of the device and
areas would result in improved                 committee agreed that nursing staff          patient safety initiatives while per-
compliance.                                    would be more comfortable with               forming their other job responsibili-
   Originally, 13 drug libraries               brand names as opposed to generic            ties. A clinical pharmacist handled
were developed. While some CCA                 names. Each library was organized            ongoing library editing, with library
libraries contained as few as 10 med-          in the following order: maintenance          review/updating occurring a mini-
ications, the ICU CCAs used the                I.V. fluids, electrolyte replacement,        mum of twice annually. Review/
software maximum of 150 medica-                individual nonantimicrobial drugs,           updating would occur more fre-
tions/CCA. Programming parame-                 then individual antimicrobial drugs.         quently, if needed, based on the
ters for a given drug could vary               Two drug lists were generated (by            results of analysis of data from the
between CCAs. When an infusion                 brand and generic names), each list          pumps, such as identification of an
                                                                                            ADE. Biomedical Engineering was
                                                                                            responsible for data uploads and
 Strategic planning for wireless infusion technology                                        library transfers after completion of
 ♦ Ensure that hospital administration supports implementation of intelligent I.V.
    infusion pump technology in the institution.                                            revisions. Nursing was responsible
 ♦ Perform due diligence.                                                                   for analyzing data retrieved to evalu-
   –Provide thorough investigation and evaluation of products from several I.V. infusion    ate compliance with use of the safety
   pump vendors.                                                                            software and safe medication admin-
   –Involve nursing staff in the device evaluation/selection process.                       istration practices, and providing
 ♦ Assess the institution’s potential wireless capabilities or existing wireless
   infrastructure.                                                                          feedback to nursing staff and other
   –Complete the development of wireless infrastructure prior to device purchase.           stakeholders.
 ♦ Involve staff in the in-service education plan.                                             Stakeholders adopted a policy of
   –Carefully select and utilize staff-based “super users” to help ensure successful        virtually 100% compliance with the
   staff education regarding new technology prior to and during implementation.             use of the safety software. Exceptions
 ♦ Plan staff scheduling to insure that all staff members attend educational in-services.
 ♦ Set measurable targets and stretch goals regarding staff compliance with use of the      to this policy were made only in the
   new technology.                                                                          cases of emergency situations or if
   –Obtain staff input in setting the targets.                                              medications weren’t represented in
 ♦ Prepare budget to include expenses to reward staff who reach target and stretch          the existing drug libraries.
   goals. Plan for ongoing educational in-services to occur at 6 and 12 months after ini-      A clinical specialist from the ven-
   tial in-services.
   –Plan focused educational programs based on CQI data reports regarding compli-           dor trained nursing staffs. Night and
   ance with the new technology.                                                            day shift “super users,” clinicians
                                                                                            who received additional device

22 February 2009 Nursing Management                                                       
training, were utilized as educational     review their compliance results and       are key. It also includes involving
resources for staff at the first go-live   discuss any barriers that would           more end users in the device selec-
campus. This location’s super users        prevent their CCAs from achieving         tion process and in the drug library
then trained super users from other        satisfactory compliance rates. Inter-     development to improve their
campuses so that the latter could          ventions carried out over several         acceptance. This may also poten-
serve as educational resources. Nurse      months resulted in a positive trend       tially reduce the number of subse-
managers relieved staff on the floors      in compliance rates in all CCAs,          quent drug library revisions required
to maximize participation.                 culminating in absolute percentage        during the implementation process.
   Eight CCAs were selected for            increases in compliance rates             Stressing the importance and value
initial implementation of new              (January 2007 data) of 26%, overall.      of the safety software during the
pump/software technology: ED,              Compliance as a function of the time      training phase of implementation
Medicine/Surgery, Oncology, two            of the day revealed little fluctuation.   is also vital to helping clinicians
Obstetrics/Gynecology, locations,          Ongoing analysis of data reports          improve medication administration
Pediatrics, Surgery, and ICU). Sub-        yielded some interesting details that     practices and fully participate in
sequently, additional CCAs were            addressed the need to revise selected     patient safety initiatives. One area in
selected for initial implementation        drug libraries as well as evaluate        which initial education was deficient
since the software provides room           current practices. One example of         was among relief pool and agency
for library data for up to 18 CCAs.        such an opportunity was to address        staff. Realizing this, educational
The additional CCAs subsequently           any conflicting pharmacy depart-          efforts were repeated with this group
added prior to implementation              ment instruction medication labels        in October 2006.
were specific to patient population        so that the drug library and label           While the end user can bypass
types across the multiple campuses         instructions were congruent, and to       some aspects of the drug library to
and/or locations in the complex:           do this during the library develop-       program the device, the committee
Cardiology, Renal Services/Dialysis,       ment process.                             agreed early on that it was appropri-
Neonatal ICU, two Medicine/                   By the week of December 1 to 7,        ate for nurses to make this selection
Surgery units, and another location’s      2007, noncompliance with use of           ONLY in case of an emergency or a
ICU. Following initial implementa-         the safety software had fallen to         medication not found in the drug
tion (July-October 2005), three CCAs       only 1.2% overall (11,299 total pro-      library. With up to 6 months between
were added in March 2006 (Pediatric        grams). Alerts (hard limit, soft          library revisions, using the “no drug
ED, Cardiac Catheterization Lab,           limit edit, and soft limit override)      selected” entry may be necessary
and ICU [Antimicrobials]).                 occurred in 0.5%, 0.3%, and 5.5%          more frequently than desirable. The
                                           of programs, respectively. For only       only way to reduce such selections
Results                                    one CCA, the noncompliance rate           is to reduce the maximum interval
Implementation of intelligent pump         exceeded 1.9%. The range for hard         between library updates.
technology was delayed until com-          limit and soft limit edit alerts was         Another strategy to improve
pletion of the institution-wide wire-      0% to 1.2%, and for soft limit over-      compliance with software use
less infrastructure. In June 2005,         ride alerts it was 0% to 24%. During      involved making routine unan-
contractual arrangements were              this same period, there were a total      nounced CCA spot checks of
finalized and preparations began           of 74 hard limit override attempts.       pumps delivering I.V. infusions to
for going live. By July 8, 2005, all       Assuming that all 74 attempts             patients, looking for the       icon
safety software policies and proce-        would have resulted in ADRs had           on the screen (indicating that the
dures had been completed and 80%           they been “successful,” the poten-        safety software wasn’t in use). This
to 95% of nursing inservices had           tial cost avoidance was $647,500.         allowed nursing management the
taken place. On July 11, 2005, final                                                 opportunity to learn why the clini-
approved versions of the drug              Take-aways                                cian wasn’t using the safety soft-
libraries were ready for uploading         In retrospect, many lessons were          ware and immediately reinforce
into the infusion pumps.                   learned during the implementation         hospital policy regarding compli-
   Initial compliance rates were dis-      process that may improve prospects        ance, as well as educate the clini-
appointingly low. The Director of          for higher and sustained compli-          cian on correct pump operation.
Operations scheduled meetings with         ance rates in the future. Ongoing         Reporting the results of these spot
individual nurse managers of each          staff and administration education        checks, in addition to sharing pump
CCA and had focused meetings to            and reinforcement of that education       CQI data with the staff, has resulted                                                        Nursing Management February 2009 23
Intelligent infusion

in a “healthy competition” between           Wireless systems can provide               3. Rosenthal K. Smart pumps help crack
CCAs—and raised compliance rates.         bidirectional communication—from                 the safety code. Nurs Manag. 2004;
Staff can witness firsthand the true      server-to-pump and pump-to-server.
                                                                                        4. Preventing Medication Errors: Quality
value of the software when reports        Server-to-pump communication                     Chasm Series. Committee on Identify-
indicate ADEs that have been              allows the facility to transfer hospi-           ing and Preventing Medication Errors.
avoided as a result of its use.           tal-specific drug libraries and con-             Aspden P, Wolcott J, Bootman JL, Cro-
   Examples of actual programming         figure wireless/network operating                nenwett LR, eds. Institute of Medicine;
errors are anonymously shared with        parameters to pump from a remote
                                                                                        5. Adachi W, Lodolce AE. Use of failure
staff to illustrate the value of always   location. Pump-to-server communi-                mode and effects analysis in improving
using the safety software. For exam-      cation allows the pump to upload                 the safety of i.v. drug administration.
ple, an insulin dosage of 1.5 units/hr    and report all events (program                   Am J Health Syst Pharm. 2005;62(9):
was prescribed, but a value of 105        start/stop, dose limit alerts, power             917-920.
                                                                                        6. Wetterneck TB, Skibinski KA, Roberts
units/hr was keyed in. As the             state changes, etc.) and alarms to
                                                                                           TL, et al. Using failure mode and effects
upper soft limit of 20 units/hr was       the server as they occur. Lastly,                analysis to plan implementation of smart
exceeded, the clinician was warned        wireless technology allows for                   IV pump technology. Am J Health Syst
and corrected the entry.                  remote software upgrades.                        Pharm. 2006;63(16):1528-1538.
   Another case involved the use of                                                     7. Siv-Lee L., Morgan L. Implementation
                                                                                           of wireless ‘intelligent’ pump IV infu-
propofol for sedation in the coro-        Uncompromised care
                                                                                           sion technology in a not-for-profit aca-
nary catheterization lab. A dose of       At EHS, implementation of wireless               demic hospital setting. Hosp Pharm.
65 mcg/kg/min was incorrectly             intelligent infusion pump technology             2007;42:832-840.
keyed in as 665 mcg/kg/min. As the        occurred transparently, without any           8. Rothschild JM, Keohane CA, Cook EF,
upper soft limit of 200 mcg/kg/min        compromise of patient care. Many                 et al. A controlled trial of smart infu-
                                                                                           sion pumps to improve medication
was exceeded, the error was caught        lessons were learned during imple-
                                                                                           safety in critically ill patients. Crit Care
and corrected.                            mentation that explained the initial             Med. 2005;33(3):533-540.
   Equal emphasis is given to teach-      suboptimal compliance with safety             9. Cassano AT. IV medication safety soft-
ing about underdosing errors, as          software use. From these, strategies             ware implementation in a multihospital
these, too, can have catastrophic         were developed to increase software              health system. Hosp Pharm. 2006;41:
                                                                                           151-156, 2006.
consequences. For example, heparin        utilization rates, resulting in steadily
                                                                                       10. Fanikos J, Fiumara K, Baroletti S, et al.
orders were written for 1,200 and         improving compliance rates.                      Impact of smart infusion technology on
1,000 units/hr, but doses of 12 and          Wireless technology has allowed               administration of anticoagulants
10 units/hr were keyed in. This           prospective monitoring, the avoid-               (unfractionated heparin, argatroban,
underdosing could have caused             ance of ADEs through prompt inter-               lepirudin, and bivalirudin). Am J Car-
                                                                                           diol. 2007;99(7):1002-1005.
worsening thrombosis. As the keyed        vention, and the timely education
                                                                                       11. Larsen GY, Parker HB, Cash J, O’Connell
values were below the lower soft          of healthcare professionals regard-              M, Grant MC. Standard drug concentra-
limit of 700 units/hr, clinicians were    ing potential ADEs. As word of the               tions and smart-pump technology
alerted to the substantial underdoses     value and the power of the infusion              reduce continuous-medication-infusion
and corrected their entries.              safety software spreads throughout               errors in pediatric patients. Pediatr.
   The major advantage of wireless        the nursing units, staff members are
                                                                                       12. Wilson K., Sullivan M. Preventing med-
technology is the ability to access       increasingly believing in its value              ication errors with smart infusion tech-
data in “real time” so that monitor-      and reporting that they’re uncom-                nology. Am J HealthSyst Pharm. 2004;
ing can be done in a prospective          fortable using infusion devices                  61(2):177-183.
fashion and interventions can take        without safety software. NM                  13. Anonymous. JCAHO’s National Patient
                                                                                           Safety Goal for infusion pump free-flow
place before ADEs occur. This may
                                          REFERENCES                                       protection: ECRI’s assessment of the
improve the retention of corrective                                                        protection offered by general-purpose,
                                           1. Husch M, Sullivan C, Rooney D, et al.
measures, especially those involv-            Insights from the sharp end of intra-        PCA, and ambulatory pumps. Health
ing new technologies. Wireless tech-          venous medication errors: implications       Devices. 2004;33:430-435.
nology is a tremendous time saver,            for infusion pump technology. Qual Saf   14. Dulak S.B. Smart IV pumps. RN. 2004;
                                              Health Care. 2005;14(2):80-86.               68(12):38-43.
allowing access to current data
immediately, and allowing ready            2. Eskew JA, Jacobi J, Buss WE, et al.
                                              Using innovative technologies to new     At Erlanger Health System, Chattanooga,
access to data from physically sepa-          safety standards for the infusion of     Tenn., Linda Morgan is former director of
rated institutions (separate campuses         intravenous medications. Hosp Pharm.     operations and Lor Siv-Lee is a clinical
of one facility).                             2002;37:1179-1189.                       pharmacist.

24 February 2009 Nursing Management                                                    

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