Improving Intravenous Therapy: Opportunities for Designing the Next Generation Infusion System Part 3 – Workflow Efficiency & Cost-Effectiveness
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IMPROVING INTRAVENOUS THERAPY: OPPORTUNITIES FOR DESIGNING THE NEXT GENERATION INFUSION SYSTEM PART 3 – WORKFLOW EFFICIENCY & COST-EFFECTIVENESS AUTHORED BY: Matthew B. Weinger, MD, MS Andrew Kline, BA Department of Anesthesiology, Vanderbilt University School of Medicine INTRODUCTION In this three-part series, we strive to provide an overview of the current status and apparent effectiveness from the user’s point- of-view of infusion pump design. We acknowledge the advances in the field while highlighting opportunities for future improvements. In focusing on some of the usability issues of current pump interfaces and insufficient interoperability, we highlight some of the existing pitfalls and offer human factors-based guidance for next-generation designs. Here, we define infusion pump usability as the relationship We focus on issues related to the between the technology and clinicians’ ability to use that technology general usability, process efficiency and to attain their work goals effectively, safely, efficiently, and with both clinician and patient satisfaction. cost effectiveness of infusion pump use. In this, the third part of the series, we focus on issues related to the general usability, process efficiency and cost effectiveness of infusion pump use. We also address current shortcomings of the integration of infusion pump technology with medication management software. 1 Workflow Efficiency and Cost Effectiveness An important added benefit of optimal pump designs is the prospect of significant cost savings. Each preventable ADE has been reported to cost nearly $9,000,[1] and smart pumps could, through built-in designs to adhere to the “Rights,” decrease the incidence of ADEs (see Part 1 of this series for more information on this topic). Indeed, not only is avoidable patient harm wrong, it has proven to be expensive. Moreover, care process inefficiencies cost the healthcare system significantly in an era when we are spending far too much for the care quality offered. Each preventable ADE has been reported to cost nearly $9,000,[1] 2 Cost of Drug Errors The Society for Actuaries suggested that the financial cost of medical errors was nearly $1 trillion per year when including both the direct and the indirect (e.g., lost and decreased patient life quality) costs.[2] Considering the impact of IOM’s arguably conservative 2001 estimate of nearly 100,000 medical error-related deaths annually, researchers and policy experts have called medical error ‘America’s most important public health issue’. What might seem like a small error can snowball, producing exponential effects on the patient and their cost of treatment. Without a system-wide focus on quality of care, the moral and financial burden of avoidable injury and death will continue to plague healthcare systems worldwide. Preventable medical harm, as one of the top ten causes of death in the United States, is an epidemic that must be addressed through new approaches that are based on the best available evidence. Technology has a role in reducing injury and cost, but only if it is designed and implemented correctly. We now focus on opportunities for infusion technology to be contributors rather than detractors to the efforts to substantially improve the overall value of healthcare processes. Without a system-wide focus on quality of care, the moral and financial burden of avoidable injury and death will continue to plague healthcare systems worldwide. 3 Pharmacy Inefficiencies Drug library creation and maintenance A recent survey found that hospitals using smart pumps typically adopted this technology due to “inventory age and failure” rather than as part of an overarching “safety strategy.”[3] Moreover, these hospitals were unable to integrate their new pumps with other medication management technologies (i.e., CPOE, BCMA), thereby limiting the ability of their pumps to fully address the Rights. As one indication of the limitations of Dose Error Reduction Software (DERS), only about one-half of the hospitals surveyed implemented hard limits on their pumps. Further, a major reason for DERS noncompliance was incomplete or outdated hospital drug libraries. For smart pumps to attain their safety improvement potential, drug libraries must be maintained and trusted by the staff. Many installed infusion pumps still do not have wireless functionality; these pumps need to have their libraries uploaded manually, a time-consuming (and therefore expensive) burden on the organization’s Healthcare Technology Management (HTM, formerly called clinical engineering) professionals. In most hospitals, the ongoing management of the pumps’ drug library typically falls to pharmacists. Given hospital pharmacists’ current workload and the rapidly changing landscape of available pharmaceuticals, it can be extremely challenging to keep a pump’s drug library up-to-date. To the extent that newly available medication safety information has not yet been implemented in a drug library, preventable harm may reach the patient. Another risk of an out-of-date drug library is that clinician users will not find a desired drug in the library and then bypass the DERS safety features in favor of unlabeled milliliter per hour infusions. 4 Nurse Inefficiency/Workflow Issues Much of inpatient nurses’ time is consumed by ‘low value’ tasks (bundled into what is often called ‘indirect patient care tasks’). Infusion pumps are a major contributor to these care process inefficiencies. According to modern quality improvement practices such as LEAN or Six Sigma, such tasks, which do not generate real value for the organization or the customer (in this case, our patients), should be minimized if not eliminated. In the case of infusion therapy, lower value time-consuming nursing tasks included searching for available pumps, priming tubing (including air elimination), manual pump programming, responding to false or unnecessary pump alarms, and managing tubing spaghetti (i.e., tangled plumbing) and secondary infusions. Redesign of infusion technology must consider and address these inefficiencies. Given the very high cost of nursing in most facilities, efforts to reduce these low value tasks will improve nurses’ job satisfaction and yield significant cost savings for the organization. In the following sections, we discuss specific opportunities for improvements in infusion therapy. According to modern quality improvement practices such as LEAN or Six Sigma, such tasks, which do not generate real value for the organization or the customer (in this case, our patients), should be minimized if not eliminated. 5 Multiple Pump and Tubing Management When administering multiple infusions to a single patient, pump consequence of numerous infusions in the same patient is fluid and tubing management is currently a frustrating, time consuming, overload. In the patient on fluid restriction (e.g., someone with heart and error prone task for both nurses and anesthesia professionals. failure or brain injury) neither the pharmacist nor the bedside nurse As a worst-case example, imagine a cardiac surgery patient (either may be aware that the myriad infusions of intravenous medications in the OR during surgery or in the ICU immediately afterwards) accumulate to a total fluid volume that exceeds the desired level of who is on a dozen or more infusions of vasopressors, inotropes, hydration. Thus, when there are multiple infusion pumps on the same sedatives, analgesics, muscle relaxants, antibiotics, pro-coagulants, patient, the pumps should communicate with each other thereby antiarrhythmics, electrolyte replacements, and blood products, each enabling appropriate bedside decision support related to drug-drug with its own pharmaceutical constraints (e.g., drug-drug interactions interactions, drug incompatibilities, and total fluid therapy goals. and incompatibilities, flow rate limits, etc.). These infusions, as well as In addition to a dearth of effective tubing management carrier and volume replacement fluids, are infusing through multiple technology, the management of numerous infusion pumps is peripheral and central intravenous routes. You can see how difficult it problematic. In the typical ward patient on just one or two infusions, can be for the clinician to maintain an accurate mental model of what the total space (or volume) and weight consumed by 1-2 infusion drugs are administering into what catheters. Current infusion systems pumps, tubing, and an IV pole is usually manageable, although the do little to support this critical management task. The clinician is risks of physical harm during transport is well described. But now constantly fighting with (and sometimes tripping over) equipment and consider our cardiac patient who may have as many as 16 pumps tubing. Errors are common and adverse consequences have been well at the head of the bed (along with monitors, ventilators, and other documented. supportive technology). The total weight and bulk of pumps, fluid The effective coordination of concurrent therapy is important. sources, and tubing is a major impediment to rapid access to the Two medications being infused by different pumps may be patient as well as safe and efficient clinical practice. Further, current contraindicated to be infused through the same IV line. The multiple line infusion pumps have numerous different bags of drugs concurrent infusion of two drugs, one acidic and the other alkaline, and fluids hanging above them. Use errors are commonly reported can produce an insoluble salt that occludes the IV. Alternatively,