Using Clinical Data Categories with the Pyxis MedStation system Using Clinical Data Categories Clinical Data Categories (CDCs) are a Pyxis MedStation system software tool that will allow facilities the opportunity to customize data collection or provide information to the end user. This information can be collected from and provided to end users when medications are removed from, returned to, or wasted at the Pyxis MedStation system. CDCs can be limited to removal of medications during the override function. Used appropriately and judiciously, CDCs can help reduce the possibility of medication errors. CDCs can be used in various ways to enhance clinical care and process monitoring: Prompt Nursing staff to enter information for data collection on quality review activities, drug use evaluation, or research studies Communicate important instructional or educational information Pass clinical information to an electronic charting system Objectives This guide covers the following topics: Pyxis MedStation system version specifications Examples of how CDCs can be used Charting implications Reporting General considerations in using CDCs CDC setup Specifications The following table details Pyxis MedStation system specifications: Pyxis MedStation system version Types of CDCs Number of CDCs Number of characters 2000 4.1 2000 4.2, 3000, and later versions Remove Return Waste Remove Return Waste 15 30 200 60 1
Examples of how CDCs can be used The following chart contains examples of ways CDCs might be used: CDC List name Sample responses Examples of use Heparin Has patient received Lovenox today? Reason for use Reason for use For pain For temperature If no, ADMINISTER If yes, CANCEL & CALL PHARMACY Pain scale Pain scale 1 2 3 4 5 You may want to consider type in for this option as 10 displays before 2 Or, remember to chart pain scale on MAR Route of admin Route of admin IV IM Heparin to avoid excessive anticoagulation Tylenol Morphine; may be used on removal or on administration if electronic charting interface is utilized If electronic charting interface is utilized Only IM Only IM (OKAY) I will give IM Penicillin G Procaine Penicillin G Benzathine Must dilute in 10 ml normal saline Must be diluted before use (OKAY) I will dilute in 10 ml normal saline Allergies Check allergies (CALL RPh) possible allergy (DO NOT GIVE) has allergy (OKAY) not allergic PCN allergy Do not give if Penicillin allergic (CALL RPh) possible allergy (DO NOT GIVE) has allergy (OKAY) not allergic All antibiotics at nonprofile stations and override at profile stations Unasyn Zosyn INR What is current INR? (Type in response) Warfarin Best to use with charting interface; warn Nursing that they will need this info before removing INR INR <1.5 give dose and call MD 1.5-2.0 (OKAY TO GIVE) >2.0 hold dose and call MD Do not crush Do not crush (CALL RPh) pt has feeding tube (OKAY) patient can swallow Vancomycin DUE Reason for vancomycin order MRSA Penicillin allergic Return Reason for return Patient off floor Patient asleep Patient nauseated Patient refused Titrated dose IV push rate Give IV push over XX minutes IV infusion rate Is vanco for IV infusion? Yes, infuse over 90 minutes No, used for irrigation Warfarin Sustained release tablets IV Pepcid IV vancomycin 2
Override reason (problem assessment period) Reason for override New admission and Pharmacy closed Patient emergency MD verbal order and MD at bedside Override reason Reason for override Not an emergency, will wait Code 90 Acute pain HR/BP outside limits Nauseated Allergic reaction Antidote/reversal agent Magnesium alert Lidocaine PF For Eclamptic seizure tx only Is it preservative free? (DO NOT GIVE) cancel remove (OKAY) usual dose = 4 grams (CALL PHARMACY) mis-filled med (OKAY TO GIVE) no preservative Paralytics Is patient on ventilator? (CANCEL REMOVE) not on ventilator (OKAY TO GIVE) patient on ventilator Heparin flush Use NS for routine line flush (OKAY) heparin is indicated not NS To assess Nurse s perspective of why they need to override; to be used only for a short period to identify problems then move to CDC below To meet Joint Commission standards for override documentation Vecuronium Heparin flush on override or nonprofile Pyxis MedStation system Anesthesia kit Do not return kit here Return to USED KIT pocket Returning anesthesia kits Used anesthesia kit Hypaque allergy Central line Is anesthesia record included? Allergic to iodine/ contrast? Infuse through central line only YES anesthesia record inside (Call RPh) possible allergy (DO NOT GIVE) has allergy (OKAY TO GIVE) no allergy (CANCEL REMOVE) no central line (OKAY) patient has central line Return bin Don t return to bin OKAY I need to waste Carpujects Hx seizures/ renal failure Drug protocol Maximum use per day Hx seizures/renal failure Please refer to protocol ### Maximum is 4g/day (CANCEL Page RPh) seizure/renal (OKAY TO GIVE) no history (CANCEL) total >4g in 24 hours (OKAY) total <4g in 24 hours Drug interaction Drug interaction Do not administer drug A if patient receiving drug B Drug name alert High alert medication Drug/procedure interaction Feeding tube warning HydrALAzine is used for blood pressure High alert med Drug/radiology procedure interaction D/C feeding 1 hour before and for 2 hours after administration via NGT OK, ordered for blood pressure (CANCEL) need HydrOXYzine for itching Double check dose/math before administration D/C metformin 48h before procedure Resume 48 hours post procedure OK, no procedure scheduled (CANCEL) need to wait (OKAY) patient does not have NGT (OKAY) tube feeding d/c > 1 hour Returning anesthesia kits Acetaminophen Any 2 drugs on the override list that may interact Hydralazine on override or nonprofile Pyxis MedStation system Insulin Metformin Phenytoin 3
New drug education Angiomaxtest 6/1-6/8 Indicated for PTCA May be used with Aspirin Rec. dose 1 mg/kg IV bolus followed by 4 hr infusion at 2.5 mg/kg/hr ADE Is this to treat an ADE? Yes No Waste old patch Fentanyl Waste old patch: Cut into 4 pieces and put in sharps container Return to Pharmacy Waste CDC Controlled meds in unit dose cups Return to Pharmacy: Too big for return bin Angiomax: Give the information for 2 weeks Dextrose 50% Diphenhydramine Epinephrine Hydroxyzine Methylprednisolone Naloxone Flumazenil Vitamin K Protamine: Black box warning pregnancy do not handle medication if pregnant or planning to become pregnant OK I will waste N/A 1st patch Waste location Waste location Sink sharps container States that require waste location to be documented Number of days used Number of days used 1 2 3 Fentanyl patch Pyxis MedStation system showing a Nurse removing Benadryl 4
Charting If the hospital has an electronic charting system and charting interface with the Pyxis MedStation system, CDCs can be used to pass charting messages, such as site of injection, pain rating, apical pulse, blood glucose, blood pressure or other pertinent clinical patient observations, back to the electronic chart. Careful testing should be completed if electronic data is expected to transfer to a third-party vendor for charting. Without a charting interface, Nurses may be required to document this information on a manual medical record. Therefore, careful discussion should be given to the necessity of requiring this information at the point of removal. Reporting on CDC information The following section describes information on CDC reports available on Pyxis MedStation systems: For Pyxis MedStation system 4.1 and earlier, the only CDC report available at the console is the All Station Events report. This report contains all of the medication activity data, including CDC information, and may be very detailed. This report can be limited by selecting only the medications that have a CDC attached to them at the formulary level. For Pyxis MedStation system 4.2 and later, a specific CDC report is available. This report allows the user to select criteria such as CDC type (remove, return, waste), CDC, medication, medication class and unit. Currently, the report cannot be limited by CDC response. The Pyxis MedStation system archive data stores the CDC responses in the file*.cdc. This data may be used to retrieve all responses users enter for analysis using a product such as Pyxis Consultant version 1.80 or later, or a third-party data mining tool. CDC data is not supported by Pyxis Reporter software. Regulatory concerns In some states, Pharmacy boards require that Nurses record the name of the ordering Physician for controlled substances. A CDC can be set up to list prescribing Physicians. The CDC is then attached to all controlled medications. Other states require the waste location to be documented. General considerations for using CDCs CDCs provide a speed bump to remind users about important information to consider when removing medications, and prior to administering them. If used selectively, CDCs are an important tool that might prevent medication errors. However, if CDCs are used too frequently, users may see them as nuisance notices and not fully read or comprehend the warnings, thus compromising the effectiveness of the information. CDCs can be configured by device and medication and can also be configured for a mandatory or optional response. This flexibility allows the message to be displayed on select devices or all devices. CDCs may be used at Pyxis MedStation systems in both profile and non-profile mode. Guidelines for using CDCs Consider the following issues when deciding how and when to use CDCs: CDCs add process steps to removing, returning or wasting medications CDCs should be used carefully, with the end users time in mind Directives and responses should be as brief as possible Lists should be short to minimize the need to scroll Nurses should be educated before CDCs are activated Before implementing a new or upgraded system, it is best practice to create several CDCs so users can be educated on CDCs along with any other new features The most commonly used reason should not be placed at the top of the list to encourage end users to read all responses before making a selection Nursing and Pharmacy should work together to determine which CDCs would be most beneficial to implement at their facility Setting up CDCs For CDCs to work, they must be created, assigned to formulary items and then turned on at the device level. The device toggle allows for greater flexibility in using the CDCs. For example, if CDCs are used to track ADEs, you may elect not to capture Flumazenil use in the recovery room. When a CDC is attached to a formulary item, it will prompt the user for a response each time the item is removed, returned or overridden, depending on how the CDC is created. It cannot be limited to the first time that the item is removed, returned or overridden. 5
CDCs at the console The following illustration shows CDC setup at the console: Name: Define the CDC for the console. Select a name that describes the purpose of the CDC. Type-in only: Select this option if you do not plan to give the end user a selection list and require a typed response. For example: Pulse rate. Single: Select this option if only one response is allowed. For example: ADE response. Multiple: Select this option if users can select up to three responses from a single CDC. For example: With charting feature, multiple observations. Required: Select this option if you want to force the end user to respond before removing the medication. For example: INR. NOTE: Clearing the Required check box allows the user to bypass entering clinical data. Once: Select this option if you want to allow users to respond to the same CDC for multiple medication removals with the same CDC response. For example: To document the ordering Physician for multiple medications for the same patient. Override only: Select this option if you want the CDC to display only when the medication is removed using the Override feature. For example: Allergies. Type-in allowed: Select this option if you want to give the user the choice of typing in or selecting an answer from a list. For example: Reason for override. One list: Select this option if you want to set up one selection list for the user (used in most CDCs). Several: Select this option if you want to set up several lists for the user. 6
CDCs by device The following illustration shows CDC setup for an individual Pyxis MedStation system: 7
Creating a CDC for tracking adverse drug events Use the following guidelines to set up a CDC for tracking adverse drug events: 1. From the Pyxis MedStation console s main menu, select System Setup > Clinical Data The following screen appears: 2. Select any category that has not been defined and click Edit The Clinical Data Edit screen appears: 3. In the Name field, enter ADE 4. In the left box below the Name field, click Single to allow users to enter only one response to the ADE question 5. In the right box below the Name field, click Required to force users to select a response before proceeding 6. In the Clinical Data Lists area, click One List 8
7. Click Add The Add List Name and Responses screen appears: 8. In the Name field, enter Is this being used to treat an ADE? 9. Click Save: The Add button is activated 9
10. Click Add The Add List Name and Responses screen appears: 11. In the Response field, enter the response you want to appear on the Pyxis MedStation system screen (for example, YES Adverse Reaction) and click Save 12. To add more responses, repeat steps 10 and 11 until all desired responses have been entered 13. When you are finished adding responses, click Save and then click Close 10
Setting up the formulary Once a CDC is created, it must be assigned to the appropriate formulary items. If a medication is assigned to several CDCs, the order in which the CDCs are assigned determines the order in which the system displays the CDCs. For example, if a user first assigns an ADE CDC to Benadryl and then assigns an Override Reason CDC to Benadryl, the ADE CDC will appear first on the screen when the user accesses Benadryl. Up to four CDCs can be assigned to a medication for a Remove, Waste and Return transaction. Follow the guidelines in this section to assign a CDC to formulary items. 1. From the Pyxis MedStation console main menu select System Setup > Formulary Management > Formulary 2. Select the formulary item to assign to the CDC For an ADE CDC, formulary items might include the medications listed in the article published in the journal Formulary or those you have targeted to monitor at your facility. 3. Click the Formulary Categories tab 11
4. From the Remove Clinical Data drop-down list, select ADE The Save button is activated: 5. Click Save 6. To assign additional medications, repeat steps 2 through 5 for each medication 12
Setting up a CDC for a unit For the CDC to appear on the Pyxis MedStation system s display screen, it must be activated at the unit. Follow the guidelines in this section to activate a CDC at a unit. 1. From the Pyxis MedStation system console main menu select System Setup > Devices 2. From the list of devices, select the Pyxis MedStation system where the CDC should be available 13
3. Click Edit and then click the Clinical Data tab 4. From the CDC list, select the desired CDC (in this case ADE) 5. Click Activate/Deactivate Clinical Data 6. Click Save, and then click Close 7. Log off the console NOTE: If a medication is used throughout the facility, but an ADE CDC only needs to be displayed in select care areas, a separate ADE CDC will need to be created for the medication, and then assigned to the desired areas. For example, an article published in the journal Formulary mentioned that a facility planned to stop tracking Romazicon in the recovery room. To facilitate this, an ADE CDC was assigned to all medications except romazicon using the process described above. Another separate ADE CDC that has similar wording was created for Romazicon and activated at all Pyxis MedStation systems except those in the recovery room. 14
References: 1. Published articles: http:// www.formularyjournal.com, March 2002. Adding query screen to Pyxis machines: Simple strategy drastically improves ADE capture rate. CareFusion provides this document for use as a general resource only. Anyone using this document should determine whether it is compatible with applicable state laws, regulations, professional practice guidelines and accreditation standards. Use of this document should be at all times governed by professional judgment of the user. 2010 CareFusion Corporation or one of its subsidiaries. All rights reserved. MedStation and Pyxis are trademarks or registered trademarks of CareFusion Corporation or one of its subsidiaries. DI2078 (1010/PDF) CareFusion San Diego, CA carefusion.com