1. 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

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

3. 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

4. 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 Oct;19 Suppl 3:i31-5. doi: /qshc
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.
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 Oct;19 Suppl 3:i31-5. doi: /qshc
Discrepancies between medication orders and infusion pump programming in a pediatric intensive care unit.
Russell RA1, Murkowski K, Scanlon MC.

5. 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

6. 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 – .35 FTE each
HCIS – Networking – .05 FTE
Pharmacy
RPH 0.50 FTE for 6 months,
Techs 0.50 FTEs for 6 months
Library cleanup
Nursing – Infusion Pump Device – .55 FTE
Bio Engineering – FTE each
HCIS – Interfaces – .10 FTE
HCIS – Clinical Applications – .25 FTE each
Nursing Informatics – .45 FTE each
At the close of the project the
Total actual hours logged was approximately
3000 hours.

7. 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)

8. 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

9. 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

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

11. REMEDI Guardrail Usage

12. IKP Integration Reports

13. Infusion Programming

14. Infusion Programming

15. Integrating High Risk Meds

16. Epic Pump Integration Compliance

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

18. 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

19. Iowa’s Wave to the Kids