"We've been bar-coding medications since 2003 and this was the next logical step in enhancing our process for administering intravenous medications safely," recalls Tina Suess, R.N., Cerner Bridge system administrator for Lancaster General Health, the delivery system anchored by the 638-bed hospital.
Cerner Bridge is the name of the point-of-care bar code medication administration software from Cerner Corp. that the hospital uses. The Cerner Classic pharmacy information system at the facility provides medication order information to Cerner Bridge, making bar-coded validation possible at the bedside.
The hospital implemented approximately 1,100 Hospira Plum A+ smart pumps embedded with MedNet programming software, both from Lake Forest, Ill.-based Hospira Inc. MedNet provides decision support, checking medications within a pump's drug library and alerting a clinician when pump programming is outside the dose limits.
Hospira and Kansas City, Mo.-based Cerner had previously partnered to link other pumps and systems, and now wanted to integrate the MedNet and the Bridge software to better support automated programming of the pumps.
Taking out manual steps to program pumps, while using bar code technology to verify the medication order, dose, rate and patient can significantly reduce the chance of medication error. By automatically populating the correct drug, concentration, weight and dose/rate from the pharmacy and bar-coded medication administration systems, the number of steps to program a pump has been reduced from 17 with a manual process to seven with auto-programming, says Amanda Prusch, PharmD, medication safety pharmacist at Lancaster General Health.
Early Benefits
Following preparations and extensive testing in 2006-2007, the hospital piloted intravenous interoperability in a single nursing unit in July 2008. By January 2010, 18 units with 294 beds were live, out of about 544 total eligible beds.
Benefits of the integration effort soon showed. Auto programming supported with bar code technology is generating a large amount of electronic data on patients, clinicians, drugs and warnings to analyze for quality improvement. And analysis of the data is exposing data and pump programming practices that previously were concealed within the technology or by a lack of end-user awareness.
A time-and-motion study that compared auto and manual programming processes revealed a 24 percent reduction in the time it took nurses to administer an IV medication.
But what was really eye opening about the study was evidence of the drug library not being appropriately used, as demonstrated by nurses selecting the wrong drug from the medication library, entering the patient's weight as a rate, or entering the wrong volume during manual processes, Suess says. "That was when we knew auto-programming was going to be worth it."
And there was a lot of work for two years before go-live because Lancaster General was the first to link the pumps' MedNet software with the Bridge medication administration system. "As pioneers, we had no blueprint to follow," Prusch says.
Smoothing the Bumps
Lancaster General faced a number of challenges as the integration initiative moved forward. The vendors did all the coding work to integrate the systems. But hospital personnel had to build the medication libraries and develop new processes and workflows for moving from manual to automated programming of infusion pumps. "There was a tremendous amount of testing that we did," Suess says. "Involving end-users in testing permitted us to validate software to not negatively impair the nurse's care at the bedside."
Among the workflow changes, the pharmacists now validate infusion rate changes, which offer a second verification of the rate in addition to the nurses on the floor. Further, auto-programming can not only trigger alerts if mistakes are made and require a response by the nurse, but also can force nurses to administer medications in a standardized, task-limited workflow.
Prior to auto-programming, a nurse could administer three IVs at a time, which could result in mixed lines. Now, nurses have to scan the patient wristband, medication bag and pump, then start the infusion, and repeat the process for each subsequent infusion.
Another obstacle was inconsistent connectivity and coverage with the hospital's existing wireless network once all those new wireless pumps started coming on line. For instance, pumps often are placed on the window side of a room while the medication cart is on the door side. So, the hospital had to add wireless access points along the inside edges of the facility.
But the most time-intensive job was bar coding 1,100 pumps, Prusch says. The hospital partnered with Medi-Dose Group in Ivyland, Pa., to develop a durable bar code to withstand environmental wear and tear such as frequent cleanings. And each pump needed two unique bar codes-a total of 2,200 codes. That's because each pump can infuse two drugs at the same time with each drug having its own "channel."
The channel is what is programmed to infuse the drug at a particular rate and each channel has its own unique identifier. By scanning the unique channel bar code, the Cerner Bridge software can populate the specific medication infusion details to the correct channel on the pump. The nurse then can validate the programming and manually start the pump to infuse.
Auto programming at Lancaster General has become an additional layer in improving the administration of intravenous medications, Prusch says. Adds Suess: "We're constantly learning, re-looking and modifying."
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