Optimizing ‘Bolus from Bag’ functionality Margaret Schmidt April 19, 2017

Agenda Background Best Practices Examples Implementation Electronic Medical Record (EMR) and Smart Pump Library (MDL)

Background Allina Health (MN, WI) 12 hospitals 61 clinics, 23 hospital-based clinics 49 rehabilitation locations 2 ambulatory care centers

Background Electronic Medical Record (EMR) Smart Pumps (MDL) Epic Inpatient, Clinics, Hospice, Retail Pharmacies, Affiliates 2004 – current Bolus/Load doses built as IV Piggyback (or IV Push) Smart Pumps (MDL) Baxter Sigma Spectrum 2500 pumps across all hospitals, some clinics, and EMS 2013 (6 mo timeline) MDL records built for existing IVPB Bolus/Load doses Short timeline so didn’t have time for full assessment and impact of change New pumps for existing workflows vs New pumps and new workflows IV Fluid was the only record for which Bolus was allowed upon implementation of the new Smart Pumps Optimize ‘Bolus from Bag’ at later date

Best Practices – Bolus/Load from Bag EMR Drug records for Bolus/Load Separate record No charge Naming conventions drug (concentration) ‘Bolus from the Bag’ Dose and Frequencies for Bolus/Load records Units (eg, mg, mg/kg) One Time, One Time PRN Multiple doses, PRN MDL One record for Infusion with Bolus (or Load) Allowed Mimic name in EMR on Medication Administration Record (MAR) Units Load Allowed Bolus Allowed Nurses expressed interest in functionality for other medications Heparin was developed at one hospital, but impacted standards within EMR and MDL (order sets, drug record build, MDL records, etc) HOLD on additional requests until Best Practices defined to minimize re-work and confusion Gathered nurses, pharmacists, EMR Pharmacy developers, Epic and Baxter technical support to develop Best Practices during 3-hour, face-to-face session.

Best Practices – Bolus/Load from Bag EMR Default Administer Over or Rate Barcode for BCMA Pre-made Infusions have manufacturer barcode that works for Infusion and Bolus/Load Pharmacy-prepared mixture has barcode that is specific to Infusion order; does not work for Bolus/Load MDL Starting Rate to minimize key strokes Soft Limits to provide guidance Hard Limits if needed for patient safety Used REMEDI to identify other health systems’ limits

Bolus/Load Barcode 2-D barcode for infusion order Linear barcode for Bolus order(s)

Continue to pursue interoperability Build EMR New ‘Bolus/Load from Bag’ records Concentration of Bolus/Load = Infusion Charge on Administration of Bolus/Load = NO Add Bolus/Load barcode to label of pharmacy-prepared Infusion records Remove existing IVPB Bolus/Load records MDL Update Infusion records Allow Bolus Allow Loading Dose Determine limits for Bolus/Load Remove separate record for Bolus/Load Continue to pursue interoperability

Take into consideration dosing algorithms Example - heparin EMR New Bolus/Load record Update order sets with new record Consider dosing algorithm Dose recommendations 400 - 10,000 units MDL Update Infusion record to Allow Bolus/Load Pump limit, UHL = 9999 units Take into consideration dosing algorithms

Example - heparin EMR/MAR MDL Bolus or Load?

glucose mgmt. technology and changes to order sets Example - insulin EMR New glucose management technology Bolus 0-50 units over 3-5 min Infusion 0-50 units/hr New order sets included D10% ‘bolus’ 0 -250 mL (IV infusion) D50% ‘bolus’ 0 – 100 g (IV Push) MDL Update insulin Infusion record to Allow Bolus Determine workflow for 0 units/hr Update pump library to coincide with glucose mgmt. technology and changes to order sets

Example – IV Fluid ‘Bolus’ EMR Update with Best Practices New records NaCl 0.9% Bolus from Bag LR Bolus from Bag Rate NOTE: Rate > 999 mL/hr, infuse without pump Charge on Administration From Bag (No Charge) New Bag (Charge) MDL IV Fluids without KCl always Allowed Bolus Update current workflow(s) to follow Best Practices

Implementation EMR MDL Scenarios Training/demonstration Playground environment Order Entry MAR documentation MDL Training/demonstration zzzTraining Care Area BOLUS–Train LOAD-Train Align with nursing initiative for documentation of start/stop times in EMR

Summary Define Best Practices with all stakeholders engaged Align Best Practices across technologies (EMR, MDL, algorithms, dosing tools) Optimize existing workflows with Best Practices Implement as bundle rather than one-off Take time to do it right, but schedule time to optimize post-implementation Optimize workflow Assess workflow from Order Entry to Administration (including BCMA) Optimize ‘Bolus’ IV fluids in ED to eliminate need to retrospectively review charges Bundle with other initiatives to train nurses regarding improvements for IV Administration Saturate their workflow with the Best Practices instead of infrequent encounters SUCCESS!!!