Hi, my name is Teresa, and I have been a nurse since 1995. I have seen many advances in technology used in healthcare. Change is usually challenging but with proper planning, it can be less painful. Once again, we need a change to happen for better patient outcomes! I want to present a problem with solutions, discuss challenges, and the implications for nursing. After reading my blog, check out the vendor website: Synchronized Intelligence and their video!
Identification
and explanation of the problem
Paper has quickly become the taboo of patient safety in
healthcare. Writing in a chart is now such
a thing of the past, that nurses will forget to pick it up and take it with them
when the patient leaves for procedures.
The use of paper created what is called paper silos throughout the
healthcare system, where no one knew what the other was doing. Fast-forward to our current technology, and
we are now experiencing the same thing when computer systems do not talk to
each other. According to Sewell (2019, p. 248), interoperability
is “the ability of two or more systems to pass information between them and use
the exchanged information.” How the two
systems to exchange information is the technical side and the clinical side is
the ability to use that information (Harrington,
2018).
The Joint Commission provided an update in 2017 about the top four
challenging medication issues from surveys that would be the focus for 2018 (Mansur, 2017). Medication orders were top, with 49.28
percent being non-compliant (Mansur,
2017). The problems in this area are
failure to clarify orders, inconsistent range orders, and titration orders. The Joint Commission has established hospital
national patient safety goals for 2020. Focusing
on interoperability and the technology silos in the facility, this author wants
to discuss a potential intervention or solution that could help meet two of the
2020 safety goals and help address the medication problems presented in the
2017 update.
Nurses report being stretched thin at the bedside. This author has experienced the same during
my twenty plus years of experience in the nursing profession. Nurses feel pulled in numerous directions
with patient and family needs. Then
there is the added concern of quality measures, patient safety, evidence-based
practice, improving patient outcomes, and guaranteeing patient experience is at 9 or 10 on the Likert scale. Technology has presented challenges with use,
alarm fatigue, and lack of interoperability with other systems adding to the
frustration nurses feel. Each new technology
enhancement is said to save them time; instead, they end up finding a
workaround due to lack of time or understanding at the bedside.
The two national patient safety goals to address during this blog
is goal one to improve the accuracy of patient identification and goal six to
reduce the harm associated with clinical alarm systems ("National patient safety goals,"
2020). There continues to be a significant
non-compliance with using the drug libraries on the Alaris pump system. Since the implementation of the smart pumps
in 2005, the compliance of using the libraries remains significantly low
throughout the facility. Another
compliance issue is the lack of use in the electronic health record (EHR) for
documenting titration of IV medications.
A quality improvement project done by the ICU educator in 2019, revealed
that the documentation for titration of drugs is a 15-step process averaging six
minutes (K. Robinson, personal communication,
February 11, 2020). Surveying the
nurses for reasons why they do not document their titrations in the EHR, the
highest percentage in all units reported the time involved and the pace
required for rapidly declining patients (K. Robinson, personal communication,
February 11, 2020).
After QRS surveyors pointed out the need to improve the process of
documentation of IV medication titration, there were mandatory classes held to
educate staff. As of February 2020, there
is little improvement in the audits done for IV titration, and smart pump data
shows 67 percent compliance, medication scanning 90 percent, and patient
scanning 95 percent (K. Robinson,
personal communication, February 11, 2020).
The goal for 2020 is 80 percent smart pump compliance, and no specific target
percentage for IV titration documentation compliance. Medication and patient scanning goals remain
at needing 100 percent compliance.
Proposed
interventions/solutions
This author proposes the implementation of new smart pumps that will
have additional features beyond the ones currently in use. The Space Infusion Pump System, from B. Braun
Medical Inc., has been successfully integrated with the Medtech EHR using Iatric
Systems ("Integrate Smart
Pumps," 2019). Our facility
needs real-time data to impact patient outcomes and drive clinical decisions. Compliance with the features of this technology
can help reach the 80 percent goal and more.
There are 432 beds in our facility, with more coming by the end of this
year. A hospital with 286 beds was
successful in a pharmacist-led venture implementing smart pumps and EMR
interoperability (Biltoft &
Finneman, 2018). The program helped save
bedside staff time by decreasing keystrokes, pump alerts, overrides, and pump
reprogramming and capture charges
previously missed in outpatient areas (Biltoft & Finneman, 2018). IV medications are more likely to cause
patients harm if not administered correctly.
The project consisted of engaging key stakeholders, providing a rationale
for implementation, planning for implementation, collaborating, and providing an
impact assessment after roll-out.
Examining other project's successes with roll-outs can help avoid
unnecessary complications. There is a clear
need to implement this innovative technology. Using the Lean principle, quality
improvement (QI) metrics to measure performance, and forming partnerships with
key stakeholders that include the product supplier, we can have similar results
as a five-time magnet academic medical center had with an improvement to 100
percent drug library compliance (Lehr,
Pontieri-Lewis, & Zavotsky, 2019).
The Magnet center successfully integrated 1327 smart pumps into 45
departments with a timeline of three months (Lehr et al., 2019). Having a three-month timeframe requires clear
communication, ownership by stakeholders, and identification of metrics for success
(Lehr et al., 2019).
Remaining
Challenges
There
is a financial challenge to implementing this technology. However, taking advantage of crucial vendor
features can allow for capturing previous charges missed in outpatient settings (Biltoft & Finneman, 2018). Although we currently use Alaris pumps, the
equipment expands horizontally instead of vertically, like the Space Infusion, and
will still require us to purchase all new pumps. Another challenge with remaining with Alaris
is they have not successfully provided for interoperability with Meditech. This author suggests examining current contracts
with the Alaris vendor and then investigate conversion to the Braun vendor.
Nursing
will have to learn the new pumps, but there is significant vendor support for
training and implementation. As nurses
learn about the additional features with synchronized intelligence, they will
demonstrate buy-in ("Synchronized
intelligence," 2020). However,
as critical stakeholders, nursing needs to be represented in all stages of the process. Even with the best technology, without end-user
support, the project may fail.
Another
challenge is to make sure the point of care areas where the technology is in
use, will not add to workflow issues for nursing. The location of equipment will need evaluating
for nursing buy-in. A pump and computer should
be close to the scanner and not add steps to the scanning process. Scanners should not be tethered but free. There needs to be an understanding of the
placement of all routers and medical equipment to allow for the transfer of
data from the pump to the system.
Careful design placement is required by the departments for appropriate
data capture from devices. Medical equipment
such as portable x-ray machines is a potential barrier for data transfer. Identified prospective super users will
conduct an environmental survey of units to identify potential obstacles in
equipment placement.
Implications
for nursing
There
needs to be an improvement in documentation of IV titrations as mandated by the
QRS survey findings in 2019. The proposed
technology will address this need and at the same time, the two national
patient safety goals of improving the accuracy of patient identification and reducing
the harm associated with clinical alarm systems. With the use of iMobile technology already at
the facility, nursing will receive critical smart pump alerts to their phones
and be able to know what needs addressing before arriving in the room. Decreasing unnecessary steps to look at a
pump helps provide a workflow solution.
By scanning the patient, then the med, and lastly, the pump, real-time
data is transferred to the EMR allowing all clinicians to have access to critical
data and provide 100 percent compliance.
When nursing is titrating drugs, they can decrease the manual burden of
entering data to scanning it in or the pump will automatically send the change
to the EMR allowing the data to flow in without nursing doing anything. This feature alone helps with compliance in the
documentation. Nursing needs to have innovative
solutions to provide for better patient outcomes. Facilities can assist nursing by implementing
innovative technology at the bedside to improve workflow, patient safety, drive
technology to improve interoperability and provide QI metrics to measure performance.
References
This is awesome! Our health system has been considering pump integration for years and has plans to move forward in July 2020. The BBraun pumps are in use in many of our hospitals but will be rolled out to additional facilities prior to integration. HiMSS Stage 7 for hospitals requires integration of vital signs but looks for addition integration of clinical systems to minimize risks to patients. This was one area we would like to showcase on our re-evaluation. Our struggle is to align the flowsheet rows to ensure it functions as expected. The other interesting call out is the capturing of charges in outpatient departments. Areas such as emergency department and observation patients require a documented start and stop time which nurse often forget to capture. This leads to a manual billing process. This would be another huge win for our billing system implementation in saving chart review man hours! Great job! Kim
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ReplyDeleteGreat job Teresa. Gone is paper, however, there may still be some hospitals or small clinics still using paper I like that you mentioned the Joint Commission and the NPSG for 2020. They are all about patient safety. Improving the accuracy of patient identification. My hospital identifies patients by identification band, full first and last name, date of birth and full social security number. Despite doing this, there is still one or two that slip through the crack. They are correctly identified and returned to their ward. Smart pumps are great at figuring out titrations. I have worked with them and they are fabulous.
Joint Commission is about patient safety and decreasing medication error through transcription. CPOE would be a great tool for the doctors ("Computerized Provider Order Entry," 2019, np). This in addition to the BCMA would benefit any hospital.
References
Computerized Provider Order Entry. (2019). Retrieved from healthit.gov/faq/what-computeried-provider-order-entry
Hi Teresa, Great topic! We are also developing interoperability of infusion pumps and I think it has great pearls for safety with most medications. Titratable infusions actually worries me so I've been revising our guidelines in preparation. The reason being not only as you described titration can be labor intensive, but also because their is a huge cognitive burden to clinicians managing critically ill patients. During episodes of frequent titrations with overlapping interventions it can be almost impossible to titrate in a standard "to the minute" fashion. What I have devised is to require continuous monitoring when a patient requires frequent titration and rate doses on the MAR at least every 15 minutes. This way when we reach interoperability with the infusion pumps nurses won't go to validate the pump information and see their actions conflict with the orders by the measure of minutes. This is not to imply that failing following titration orders is acceptable, but to allow for safe practice when acuity is extremely high and multiple interventions are occurring in a period where a patient is continuously monitored. Side note, TJC is revising Medication Management Standards, you've probably seen the call for public comment from AACN. I'm very hopeful interoperability of infusion pumps will create additional safety layers as my department will just have to scan the medication and the pump will program itself. The only worry I have is automation should not eliminate double checks and it seems the more automated our practice becomes the less effective independent double checks (IDC) become. I review countless medication errors where an IDC was documented as performed. Where is the balance of automation and mindfulness and how do we teach that?
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