REMEDI Conference April 2018 Smart Pump and EHR Integration Project BD Alaris /Epic at the University of Iowa Hospitals & Clinics Bev Vermace RN MSN Infusion Device and Clinical Coordinator Division of the Chief Medical Information Officer Tammy Balk RPh Pharmacy Informatics Specialist  Pharmacy Informatics| Department of Pharmaceutical Care

Agenda Targeting hospitals that are ‘Getting Ready’ to Integrate Targeting Hospitals that are ‘Already’ Integrated---Now What?

The University of Iowa Hospitals & Clinics Iowa’s Only Comprehensive Academic Medical Center 3 Hospitals (UIHC, Children’s, Psychiatric) 811 Inpatient Beds >200 Outpatient Clinics Visits Inpatient: >33,000 Emergency Dept: 60,000 Clinic visits: > 1 Million Employees: 13,000 Physicians/Residents/Fellows: 1648 Professional Nurses: 2341 Non-physician employees: 9972 Volunteers: >1400 *About Basic facts FY 2016 Service Record 2015-2016

Patient Safety Why Did UIHC Integrate? Anytime you interject a human touch you can negatively impact patient safety. We are all humans! In a study (See reference below) done in 2010 in a PICU they found 24% of drug infusions and 42% of fluids had incorrect rates programmed. With integration, the infusion parameters are entered from the order within the MAR. The order details are sent wirelessly to the Alaris pump decreasing the amount of human touches compared to manual program the device therefore decreasing the chance for errors. See comment in PubMed Commons below Qual Saf Health Care. 2010 Oct;19 Suppl 3:i31-5. doi: 10.1136/qshc.2009.036384. Discrepancies between medication orders and infusion pump programming in a paediatric intensive care unit. Russell RA1, Murkowski K, Scanlon MC. Author information 1Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, PO Box 1997, MS 681, 9000 West Wisconsin Avenue, Milwaukee, WI 53201, USA. rarussel@mcw.edu Abstract BACKGROUND: Errors and the incorrect use of medications are significant sources of risk and harm to children in US hospitals. The risk associated with medication infusions has led to recommendations for the adoption of technologies including computer order physician entry (CPOE) and 'smart' infusion pumps despite a paucity of evidence demonstrating the ability of these technologies to reduce harm to paediatric inpatients. OBJECTIVE: To measure discrepancies between medication orders for infusions entered into a CPOE system and the medication being infused as measured by the programmed settings of the smart infusion pump within a paediatric intensive care unit. METHODS: This study used a prospective, observational design in a 30-bed paediatric intensive care unit. Data were simultaneously collected from the medication orders in the CPOE system and the bedside smart infusion pumps by trained observers. Analysis consisted of a line-by-line comparison of order observation data with the pump observation data. CONCLUSIONS: Of 296 observations of medication infusions and 231 observations of intravenous fluid infusions, the frequency of discrepancies between orders entered and pumps programming ranged from 24.3% for observed medications to 42.4% for observed fluids. Anti-infectives (100%), concentrated electrolytes (46.7%) and anticoagulants (46.2%) were associated with greatest discrepancy between orders and programmed doses. Qual Saf Health Care. 2010 Oct;19 Suppl 3:i31-5. doi: 10.1136/qshc.2009.036384. Discrepancies between medication orders and infusion pump programming in a pediatric intensive care unit. Russell RA1, Murkowski K, Scanlon MC.

Prior to Integration Workflow Scan medication/fluid into MAR Auto ID Module: Scan Patient/Med/fluid into pump Manually enter infusion parameters into IV pump OR Search Drug/Fluid Library for correct infusion Manually select drug/fluid Select wrong drug Select wrong concentration Enter the rate for the dose or the dose for the rate

Project Timeline, Schedule and Resources Resource commitment Oversight Committee – Met 1 hour/month and/or as needed.  8 resources. CMIO (Chief Medical Information Officer) Co-Project Sponsor CNO (Chief Nursing Officer) Co-Project Sponsor CPO (Chief Pharmacy Office) Co-Project Sponsor CIO (Chief Information Officer) Director – HCIS Clinical Applications Director – HCIS Technical Operations Director – Nursing Director – HCIS Foundations Project Core Team – Met 1 hour/week and as needed.  18 resources. HCIS – Project Manager – .20 FTE HCIS – Server Team – 2 @ .35 FTE each HCIS – Networking – .05 FTE Pharmacy RPH 2 @ 0.50 FTE for 6 months, Techs 2 @ 0.50 FTEs for 6 months Library cleanup Nursing – Infusion Pump Device – .55 FTE Bio Engineering – 2  @ .15 FTE each HCIS – Interfaces – .10 FTE HCIS – Clinical Applications – 4 @ .25 FTE each Nursing Informatics – 2 @ .45 FTE each At the close of the project the Total actual hours logged was approximately 3000 hours.

Lessons Learned Pharmacy John/Tammy Profiles created or in use (include therapies) Adult Pediatrics Neonatal Review and clean up library Weight base vs non weight base/BSA Dosing Testing all medications dose scenarios Fluids – not run as a secondary Updated drug library quarterly Start with EHR as the source. Make sure Guardrail is consistent with your EHR. One step meds are not included (supported)

Lessons Learned Nursing Back to agenda Lessons Learned Nursing Current workflow extra footsteps room layout computer & pump location/position in room scanner (tethered vs. wireless) Simulation testing include bedside nurses early in the implementation process. participated in Medication testing consideration & awareness of order/practice issues carrier fluid orders inability to run IV infusions at >999ml/hr get nursing unit management sign-off Testing device records/Epic flowsheet/Epic workflows & workflow validation pump module barcode Go-Live strategy & approach big bang vs. phased

We Are Integrated--- Now What? Post Integration Metrics Epic Pump Compliance Report—provides unit managers the ability to monitor if clinicians when given the opportunity to integrate at the point of MAR documentation, do they follow the proper workflow BD Alaris IKP Guardrail Usage Report—provides unit managers the ability to monitor if clinicians are utilizing the safety features (guardrails®) with each infusion

Count of Infusions in IKP vs. Epic Pump Compliance Jan. 1-31st , 2018 Total Infusions IKP = 235,282 vs. Epic = 65,510

REMEDI Guardrail Usage

IKP Integration Reports

Infusion Programming

Infusion Programming

Integrating High Risk Meds

Epic Pump Integration Compliance

REMEDI Guardrail Usage Report Pre and Post Integration Pre-Integration Post-Integration

Day-to-Day Challenges Ability to report post integration metrics from both vendors while comparing the same metrics (apples to apples) Clean way to report out integration within both vendors reporting system Validating stop times, disassociating device and entering accurate IV intakes (secondaries) Low compliance with pump integration in specific areas (ED, PACU) Re-educating staff on importance of accurate documentation. Having a training environment where staff can practice. If you don’t have a training ask for one in advance Low compliance---areas seeing the value of integration within their area Training environment---if you don’t have one….ask for it in advance

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