National Paediatric and Neonatal Standardised Infusion Smart-Pump Project
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1 National Paediatric and Neonatal Standardised Infusion Smart-Pump Project Moninne Howlett, Chief II Informatics Pharmacist IMSN Conference 23rd November 2018
2 Overview Background Project progress to date Future Plans
3 9 beds 23 beds
4 66% treated outside of Dublin
5 Medication Errors 8% 70% 10-fold / 100-fold errors (1/3 rd - infusion pump programming) 1 1. IV doses administered via infusion pumps associated with an error 3 2. Infusion errors associated with syringe pumps 4 x 3 27% Potential adverse drug events Paeds vs Adults 2 PICU/NICU Highest Rates 1,2 1 error handwritten Rule of Six infusions 5
6
7 66% Doses in PICU are offlabel / unlicensed IV Doses in NICU 1 31% < 1/10 th vial 4.8% < 1/100 th vial 1. Chappell K - Potential tenfold drug overdoses on a neonatal unit. Arch Dis Child Fetal Neonatal Ed. 2004;89(6):F483-4.
8 From Prescription to Patient Midazolam 1microgram/kg/min 3.2kg Midazolam (Hypnovel ) 5mg/ml (2ml amp) Neat = ml/hr Aim for 1ml/hr
9 Individualised Weight Based Infusions 3.2kg Rule of 6 6 x body weight (mg) in 100 ml: 1mL/hr = 1mcg/kg/min Doctor s Calculation Statement of Rate Dose Range Nurse Calculation Preparation of Syringe Calculation for Programming of Pump Traditional Pump Programming of Pump
10 74 incidents (April 2008 November 2010) Multiple 10-fold errors 10mgs /kg prescribed instead of 1mg /kg (Prescribing) Pump set at 0.5mls/hr instead of 0.05mls/hr (Pump) 600mcg drawn up instead of 60mcg (Syringe Preparation)
11 IV Paracetamol Up to May , 23 cases of accidental overdose with Perfalgan have been reported worldwide in children younger than 1 year, one of which was fatal. Themes: Human error relating to setting up infusion pumps 10 times dose calculation errors in both the prescription and administration of intravenous paracetamol.
12 Standardize and identify medications effectively, as well as the processes for drug administration. Limit the number of concentrations and dose strengths of high alert medications to the minimum needed to provide safe care 2004 standardisation of infusion devices 2007 Smart infusion pumps 2007 Ready-to-Use Solutions ISMP Targeted Medication Safety All high alert medications in all hospital settings, both inpatient and outpatient Dose error reduction software on all pumps (i.e. smart-pumps) If smart pumps not already in use in all areas, ensure capital equipment budget includes the purchase of this technology as soon as possible
13 Individualised Weight Based Infusions 3.2kg Standard Concentration Infusions Doctor s Calculation Standardised No Calculation Statement of Rate Dose Range Step Removed No Calculation Nurse Calculation Preparation of Syringe Standardised Measurable volumes Calculation for Programming of Pump Step Removed No Calculation Traditional Pump Programming of Pump Smart-Pump Technology
14 Sample OLCHC SCI Table STANDARD CONCENTRATION DRUG LIBRARY PICU - SHORT VERSION (See i-drive for full version) Drug Weight Standard Concentration Std Concentration (Normal Strength) Fluid Restricted (High Strength) Adrenaline 2.5kg 1mg/50mL 3mg/50mL >2.5-5kg 1mg/50mL 3mg/50mL >5-10kg 3mg/50mL 6mg/50mL >10-20kg 6mg/50mL 12mg/50mL >20kg 6mg/50mL 12mg/50mL Heparin 2.5kg 2,500units/50mL (Prophylaxis) >2.5-5kg 2,500units/50mL >5-10kg 5,000units/50mL n/a >10-20kg 10,000units/50mL >20kg 10,000units/50mL Midazolam 2.5kg 10mg/50mL 25mg/50mL >2.5-5kg 25mg/50mL 50mg/50mL >5-10kg 50mg/50mL 50mg/50mL >10-20kg 50mg/50mL 100mg/50mL >20kg 100mg/50mL 250mg/50mL (Neat)
15 Smart Pump Technology Safety Parameters 1. Key in weight of Pt 2. Select SCI 3. Default rate offered 4. Press Go 1. Drug Library 2. Visual display 3. Integration 4. Bar-Coding 5. Data Capture/CQI data
16 ISMP Error Reduction Strategies
17 Standardisation Am J Health Syst Pharm Aug 15;75( % US hospitals SCIs (for paed infusions) 88.1% use smart-pumps J Pharm Pharmacol Oct;70(10): 60% paediatric/ neonatal units use weight-based infusions 2/3 rd do not use a smart-pump with SCIs
18 National Project Progress 2012 Implemented into PICU, OT, CHC (OLCHC) Version 1 Original single-site paediatric drug library > 175 Staff UNI-DIRECTIONAL INTERFACE Clinical Information Management System (Philips ICCA)
19 Electronic Standard Orders
20 Pump Interface
21 Phase 2 Irish Paediatric Acute Transport Service Our Lady s Children s Hospital, Crumlin Standard Concentration Infusions Weight-based (Rule of 6) Infusions Temple Street Children s University Hospital Multi-disciplinary Cross-Site Working Group Unified Standardised Concentration Infusion Drug Library Go-live Dec 2014/Jan 2015
22 PICU & Beyond PICU (OLCHC & Temple St) IPATS Non-specialist Transport Team (NSTT) NNTP 3 Dublin Hospitals 25% admissions (400 per year) X Maternity Sites
23 2015 Transfer & Retrieval Data 46% 23% 14% 12% NNTP IPATS Non-Specialist Team Other 2015 Transfers by Source Region LEINSTER MUNSTER DUBLIN CONNACHT ULSTER TSCUH OLCHC At least 1 transfer from all 26 counties in 2015 N. IRELAND
24 Neonatal Standardisation National Audit Working Group Neonatal Advisory Group Clin Programme Paediatrics & Neonatology Library agreed Phased roll out (19 sites plus Neonatal Transport ) Maternal and Neonatal Clinical Management System (MN- CMS) Pilot Sites (Coombe & Rotunda)
25 Awards 1. Best Hospital Project Award - Irish Healthcare Awards Excellence in Patient Safety Award - Hospital Professional Awards Finalist in HMI Leaders Awards Commendation awarded
26 National Project Progress 2012 Implemented into PICU, OT, CHC (OLCHC) 2014 Upgrade and Implementation into TSCUH & Paediatric Transport 2015 National Neonatal SCI Drug Library 2016 B.Braun Drug Library Content Management System (OLCHC) Live in Coombe (6/16), Cork (11/16), Rotunda (partial) Draft National Paediatric Library 2017 Live in Kerry (3/17), Rotunda (complete) On-going negotiations with HSE, CHG NTMP agree to fund 2 x 0.5WTE posts Pharmacist/Nurse in post (Jan 2018) Processes for external centres (Wt-based & SCI) WG Paed ED Library Ver 4 library
27 Smart-Pump Team Eimear Sharon Eimear McGrath Clinical Nurse Facilitator Informatics/Smart-Pumps Sharon Sutton Senior Pharmacist Informatics/Smart-Pumps
28 Username Password Each hospital has a specific site ID Interim Measure Only
29 Smart-Pump Drug Library Development 42 Drug Lines Version 1 Original single-site paediatric drug library (2012) EXPAND 2019 Version 61 Drug Lines Master cross-site paediatric 2 drug library (2014) Neonatal SCI Drug Library 117 Drug Lines Version 3 Master cross-site paediatric drug library ( ) 15 Drug Lines Version National Paediatric 200 Drug Lines IN PROGRESS 4 SCI Drug Library Non-Specialist Emergency Departments Paediatric Tertiary Emergency Departments (NPH Urgent Care Centres) Jan/Feb 2019 Adult ICUs 2019+
30 Paediatric Adult Interface Adult Dose Caps Non-Weight Based Dosing Expand to Adults in the Adult Setting
31 Governance Pre Children s Hospital Group (Jan 2019) NAG, Clinical Programme: TOR and WG OLCHC Validation Process (Pharmacy Led) Legally Binding Contract Library will not be provided to any site without prior consent from OLCHC Legally Binding Contract Library will not be shared or altered without prior consent from OLCHC Braun Site by site arrangements for upload, training, costs Other Sites
32 Potential Future Benefits of National Standardisation Centralised Service Level Agreement (SLA) Optimising Smart capabilities of Existing Pumps Centralised Drug Library Uploads CIVAS/Pre-prepared infusions: Ready-To- Use(RTU) +/or Ready-To-Administer (RTA) Closed Loop Medication Management
33 Drug Library Management A Vision for the Future? Drug File Manager PICU OLCHC Create, Manage & Download Multiple Drug Library Files HSE Network Hospital Network/WiFi Manual Upload via USB All Sites
34 Potential Risk & Barriers Resources (Human/Capital) Governance Structures Buy-in from Regional Hospitals Resistance to Change Drug Library Consensus Differing Practices Non-compliance Divergence
35 Summary A lot done more to do Implementing Safer Infusion Practices at a National Level National and International Recommendations use of HIT Success of Multi-Disciplinary Collaboration Further Potential Benefits
36 Cormac Breatnach Consultant Intensivist, OLCHC.. AND many, many others!! PHARMACY NURSING CLINICIANS CLINICAL ENGINEERING
37 References for Medication Errors Slide 1. Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83(6): Kaushal R. Medication Errors and Adverse Drug Events in Pediatric Inpatients. JAMA: The Journal of the American Medical Association. 2001;285(16): UK Department of Health. Building a Safer NHS: Improving Medication Safety Husch M, Sullivan C, Rooney D, Barnard C, Fotis M, Clarke J, et al. Insights from the sharp end of intravenous medication errors: implications for infusion pump technology. Quality & safety in health care. 2005;14(2): Lehmann CU, Kim GR, Gujral R, Veltri MA, Clark JS, Miller MR. Decreasing errors in pediatric continuous intravenous infusions. Pediatr Crit Care Med. 2006;7:
One or More Errors in 67% of the IV Infusions: Insights from a Study of IV Medication Administration
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