1. The New Normal: Sustaining Medication Safety Gains with Infusion Pump Programming Bobbie Carroll, RN, MHA Sr. Director of Patient Safety & Informatics Sarah Giga, MS, Manager, Clinical Integration DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2. Children’s Hospitals and Clinics of Minnesota Our volumes: 12,586 inpatient admissions 19,577 surgical cases 90,673 emergency room visits 259,118 outpatient clinic visits Supporting the kids: 381 beds in 2 cities 4,526 employees 1,731 professional staff Visionary Board of Directors $650M+ annual revenue

3. Reducing Medication Errors Children’s has implemented several process improvement initiatives and technologies to reduce adverse drug events over the past several years. Smart Pump infusion system designed to achieve safety benefits through ‘guard rails’ utilization Computerized provider order entry (CPOE) designed to minimize transcription and legibility errors, plus offer standardized evidence based order sets

4. Smart Pumps – Phase One BCMA, Smart Pump programming, Infusion management (PICU pilot) CareFusion Smart Pumps implemented with Guardrails 5/2005 8/2007 CareFusion Auto-ID at the pump 3/2012 Cerner nursing documentation – iView, eMAR, I&O, PowerForms, PAL 9/2006 Cerner CPOE 5/2009 Cerner iAware for Critical Care 3/2010 BCMA, SPP, IM - Inpatient BCMA, SPP, IM – ED, Clinics, Surgery 2012 2013 9/2005 ePrescribe 10/2010

5. Why Smart Pumps? Benefits –Dose Error Reduction Software (DERS) Drug dose range checking Concentration checking –Single programming interface Modular design –Limit drugs based on profile Started with 4 profiles: NICU PICU, Med/Surg, Hem/Onc –Continuous Quality Improvement (CQI) data

6. Smart Pumps – Phase Two BCMA, Smart Pump programming, Infusion management (PICU pilot) CareFusion Smart Pumps implemented with Guardrails 5/2005 8/2007 CareFusion Auto-ID at the pump 3/2012 Cerner nursing documentation – iView, eMAR, I&O, PowerForms, PAL 9/2006 Cerner CPOE 5/2009 Cerner iAware for Critical Care 3/2010 BCMA, SPP, IM - Inpatient BCMA, SPP, IM – ED, Clinics, Surgery 2012 2013 EasyScript 9/2005 ePrescribe 10/2010

7. Auto-ID module Shared Across All Infusion Types Pre-programs elements on the pump, based on label produced when medication is dispensed from Pharmacy

8. Smart Pumps – Phase Three BCMA, Smart Pump programming, Infusion management (PICU pilot) CareFusion Smart Pumps implemented with Guardrails 5/2005 8/2007 CareFusion Auto-ID at the pump 3/2012 Cerner nursing documentation – iView, eMAR, I&O, PowerForms, PAL 9/2006 Cerner CPOE 5/2009 Cerner iAware for Critical Care 3/2010 BCMA, SPP, IM - Inpatient BCMA, SPP, IM – ED, Clinics, Surgery 2012 2013 EasyScript 9/2005 ePrescribe 10/2010

9. Development Partnership Solution Partnership for Smart Pump Programming and Infusion Management Joint effort to develop integration between Cerner EMR and CareFusion Alaris Smart Pump First pediatric hospital to implement world wide and the most advanced utilization (2012)

10. EMR Device EMR Integration Ideal End State - IV Medication Flow 10 1.Scan the patient2. Verify correct patient 3. Scan medication 4. Verify correct med, time, dose, route 6.Scan channel 5. Document medication 7. Verify correct programming of pump 6-rights plus: Auto program the pump with order detail Auto download infusion volumes into EMR*** 8. Review results in viewer (iAware)and send to EMR*** *** critical care units only

11. Rollout Status – Complete! InpatientLive Beds BCMASmart Pump programming Infusion Management Critical Care156XXX Medical/Surgical225XX 381 Unit TypeLive Beds BCMASmart Pump programming Infusion Management Emergency DeptN/AXX Preop/PACUN/AXX Short StayN/AXX RadiologyN/AX Hem/Onc clinic/Infusion Center N/AXX

12. Are we providing safer care? Safety learning reports related to medication administration events have decreased by ~ 37% Staff nurses report situations where BCMA prevented a medication error Patient satisfaction data shows a sustained improvement in parent confirmation of patient identification before medication administration Data shows on average a 57% increase in smart pump drug safety parameters utilization since implementation and is sustaining

13. BCMA Compliance Data January 2013 – June 2014 Following the ideal workflow is the safest for our patients! Organizational goal = 90%

14. Smart Pump Programming Utilization Report generation –Report from EMR –Denominator starts with all medication orders with a route=IV Not all are administered on the infusion pumps –Exclusions identified: PCA, code situations, push meds (things with a duration less than 5 minutes), medications not in Guardrails yet –Method to exclude: List of medications/form/dates to remove from denominator »List continues to be refined based on data/examples

15. Inpatient Smart Pump Programming Compliance: July 2014 SPP successful % excludes medications that shouldn’t be smart pump programmed (e.g. patient-controlled analgesia, push medications, etc.)

16. Smart Pump Safety Software Utilization Guardrails = the Smart Pump software that allows the creation of a drug library that includes: –Drug dose range checking –Concentration checking –Infusion time checking Data collection and analysis with this project identified that pre- project utilization was much lower than we knew….. Collecting the data –Combining Cerner patient location data with CareFusion infusion data to produce usage by unit

17. Guardrails Utilization: 1 month prior vs. 1 month post imp. Safety Gains: Each unit has shown an improvement in the percentage of infusions protected by Guardrails. Range = 4% - 312%. Average increase = 57%.

18. Inpatient Guardrails Utilization Sustainability Safety Gains: All units continue to use Guardrails at a higher rate than pre-technology rate July 2014: 67% of units have maintained or increased Guardrails utilization since go-live

19. Programming Method of Guardrails Protected Infusions Safety Gains: Manual programming significantly reduced across all units Smart pump programming adopted at high rate across all units

20. Alert Reduction with SPP

21. All Rolled Out – Now What? Support is over, right? Sustaining standard work Appreciate the need for ongoing support/maintenance –Nursing Informatics –Pharmacy –Information Technology –BioMed

22. Sustaining Standard Work Informatics nurse rounding process –Identify issues on the units, collect issue logs –Based on compliance data, meet with individual nurses to talk about workflow Be transparent –Share data on “good catches” –Share medication errors where BCMA was bypassed

23. Sustaining Standard Work Sharing compliance data –Used to reinforce scanning expectations –Identify medications that are not scanning or programming consistently User Name BCMA Usage % Patient Armband Scan % Medication Scan % Total Events SPP Applied % SPP Applied Events SPP Expected Events CE#####97.7%95.3%88.4%43100%66 CE#####99.0% 96.9%9678%1418 CE#####91.9% 3771%1014 CE#####87.9%84.8%87.9%3363%58 CE#####98.8% 97.6%8586%1821 CE#####99.2%96.0%91.9%12487%3439 CE#####100.0% 32100%11

24. Ongoing Required Support Increased urgency for support –Technology has now become part of patient care vs. just documentation –More on-site presence by our Nursing Informaticists Additional ongoing testing required –Upgrades and new code packages –Network/infrastructure changes –Updates to Smart Pumps now require integrated testing Report generation –Time consuming –Complex, merging different data sources –Time to actually analyze the data and validate once collected is challenging

25. Questions?