0 Organizational Overview First All Digital Hospital in U.S. Fully integrated EMR across 2 Hospitals & 60 Clinics National Valve Center Five Star Hotel for; Patients, Physicians, Nurses & and all team members! 15K Logins Daily, 35K Charts Opened Daily 1600 Patients Seen Daily 1600+ Caths Monthly 7000+ Echos Monthly Serving the State / Leading the Nation
Technology Eco-System Patient Monitoring & Infusion/Med Mgmt ECG & PACS (Xper, Xcelera, isite) EMR Education / Entertainment Nurse Connect okheart.com 1
Reality of Medication Errors Adverse Drug Events may occur in one-third of hospital patients. 1 More than 1.9 million ADEs per year. 2 More than 180,000 patients die from ADEs annually. 2 41% of fatal errors related to administering the wrong dose. 3 Med errors cost $3.5 billion to treat annually & affect 1.5 million patients. 3 Preventing just one ADE per day could save a hospital over $3 million annually. 4 Over 56% of medication errors are associates with IV medications 5 Over the last five years, the FDA has received reports of 710 patient deaths linked to problems with infusion pumps 5 61% of the most costly and serious medication errors are IV-related 6 Medication Administration Errors Using Infusion Pumps is the #3 technology hazard in healthcare 7 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 2
Workflow Comparison (Before & After) Manual Process (Over 20 manual steps/keystrokes) 1. Press Channel Select on module Select channel 2. Press Guardrails Drugs Scroll to find medication 3. Press Page Down or use alpha speed keys to find drug 4. Select/Press Drug 5. Select/Press mg/ ml 6. Press Yes to drug selection confirmation 7. Press Drug Amount 8. Enter value for Drug Amount 9. Press Diluent Volume 10. Enter value for Diluent Volume 11. Press Patient Weight 12. Press NEXT 13. Press DURATION 14. Enter Duration 15. Press Start 86% Reduction! Automated Pump Programming Process 1. Scan patient wristband 2. Scan IV Medication 3. Scan barcode on appropriate Alaris System module 4. Press NEXT on Alaris System 5. Press START on Alaris System 3
Pump Programming Workflow 1. Scan the patient s wristband 2. Scan the medication 3. Scan the pump 4. Review & Confirm 5. Sign (on computer or scanner depending on hardware) 4
5 Nursing Unit View / Alerts Alerts Routed to Wireless mobile via "Connexall"
6 Pharmacy Dashboard Patient Demographics Location Rm # Medication Order Details Current Running Infusion Time Remaining & Current Rate Pharmacy Time Remaining Distribution Status of Dispenses Priority of Next Dispense
Infusion Documentation (Inside EMR) Black text Indicates verified By Nurse Purple indicates Nurse needs to verify 7
ICU Summary (Brings it all together) 8
9 Bumps along the way Weights We found we documented weights multiple ways. We had to align our weights to one event code and create a process for nursing to document this prior to giving meds Pump Firmware Upgrades (Pump Round-up / time & Logistics) Pharmacy dedication We learned that a dedicated pharmacist to the implementation was necessary. Required a tremendous amount of time from the nursing analyst and clinical educators. Biomed and MIS/Network Engineering were also critical players
Interoperability / Cooperation Cerner CareAware CareAware Smart Pump Programming Alaris / CareFusion Connectivity Pre-Population of Infusion Parameters CareAware Infusion Management Cerner ibus Infusion Status for Documentation 2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 10
11 Troubleshooting Wasn t Easy Ability to expand/collapse each patient to see actual error log 1. Custom Organizer-Level Page in EMR / PowerChart 2. Shows each error by patient along with: a) Order ID b) Log ID c) Actual Error d) Nurse Name 3. Reports are generated to pinpoint major issues
12 What our nurses are saying It takes out that manual programming piece of it and allows the nurse just to double check what s actually going on and of course you can t go forward if you re doing something wrong. - Kristin, R.N. We all know that we re human, capable of error at any given moment on any given day. [Smart Pump Programming] takes a component of the human error out. - Denise, R.N. We ve had several examples where if the nurse had followed proper procedure and used [Smart Pump Programming] it would have prevented some pretty significant errors. - Lisa, R.N.
13 Clinical Quality 2011 Q4 (pre-project) vs. 2012 Q3 (post-project) Patient armband scanning went from 36% to 62% Total Guardrails Infusions went from 61% to 73% Total Guardrails Alerts went from 4,429 to 3,762 Severe Harms Averted went from 30 to 23 Reprogrammed Infusions went from 515 to 289 High Risk Overrides went from 88 to 46 Basic vs. Guardrails Infusions Basic went down from 14,115 to 8,859 Guardrails went up from 22,089 to 24,421
Benefits Realized 1. Preventing adverse drug events! 2. Increasing patient safety! 3. Giving nursing more time to spend with the patient a) Nurses generally spend only 30% of time doing direct patient care and technology issues are a key distractor. 4. Increased nursing satisfaction a) Several nurses have commented how they feel safer when using auto-pump programming 5. Ability to analyze data across Alaris, ibus and EMR 6. Decreased pharmacy costs due to wasted medications 14
Lessons Learned Train! Train! Train! Especially Classroom training! But also videos, job aides, emails, etc Test! Test! Test! Ensure you have the environments & equipment you need (Cert, Mock, Train, devices dedicated to this process) Understand your current processes! Do a pre-project nursing assessment to confirm what you think they are doing Promote as a tool for patient safety not as a time saver Take time to visit a site who is live or have a call Define all hospital departments and how/where you will use pump programming Properly assess your WiFi network (We no longer support wireless b ) Create a Training Check List or Script for nurses to use in training classes Consider a post-go live nursing survey to review their thoughts/implement improvements Partnership is key not only with the vendor but also internally (Nursing, Pharmacy, Biomed, IT) Don t be a Department of NO, be one of KNOW-HOW! 15
References 1. Classen, D.C., R. Resar, F. Griffin, F. Federico, T. Frankel, N. Kimmel, J. C. Whittington, A. Frankel, A. Seger, and B. C. James. 2011. Global trigger tool shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs 30(4):581-589. 2. Department of Health and Human Services Office of Inspector General, November 2010 3. Gurses, A.P., Carayon, P., Performance Obstacles of intensive care nurses (Abstract), Nurs Res. 2007 May-Jun;56(3):185-94. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/17495574 4. Westbrook et al. BMC Health Services Research. 2011. How much time do nurses have for patients? A longitudinal study quantifying hospital nurses patterns of task time distribution and interactions with health professionals 11:319. http://www.biomedcentral.com/1472-6963/11/319 (accessed April 4, 2012) 5. Vanderveen T. 2005 (May/June); 1-11 6. Timothy L'Hommedieu, Pharm.D., M.S. and Karl Kappeler, M.S., Lean Methodology in IV Medication Process, American Journal of Health-System Pharmacy, 2010; 67(24):2115-2118 7. The ECRI s TOP 10 HEALTH TECHNOLOGY HAZARDS FOR 2012 16