Building a Smart Infusion Figure 1 Phases DESIGN Preparation System Drug Library 1 Establish Team 2 Formalize Process 3 Determine Scope Introduction 4 Collect Relevant A smart infusion system is designed to minimize Information programming errors and the related risk of patient harm. Each facility develops a customized infusion DRUG LIBRARY CONFIGURATION Regular scheduled reviews for each Care Area system drug library, which includes dosing ranges 5 6 7 and other safety limits for individual drugs. During Drug Setup Care Area General Setup Pump infusion programming the pump checks the entries Settings against the drug library and alerts the clinician when a drug library limit is exceeded, preventing the 8 Review / verify / document patient from receiving an incorrectly programmed infusion. 9 Send to stakeholders for review A comprehensive drug library is critical for the effective and safe use of any smart infusion system. The effectiveness of a smart pump system's ability to TESTING Tests specific for each Care Area detect programming errors before an infusion is delivered to a patient is dependent on how well the 10 11 Clinical Scenario / Change drug library is built and maintained. Drug Testing Requests Infusion systems with Electronic Health Record (EHR) 12 system interoperability provide additional Re-Tests programming safety and facilitate clinical 13 documentation. Sign-off / Approval Figure 1 is an overview of the process to build an Go-Live with Smart Infusion Pumps infusion system drug library, including steps to EHR INTEGRATION consider for EHR integration. Mapping EHR drugs to pump drug library. Integration Testing 1 2 Design Phase Drug Auto-programming Mapping workflow Step ONE – Establish the Team EHR / Pump validation 3 4 One of the success factors for a well-built drug Integrated Clinical drug order Scenario library is collaboration from all stakeholders. testing Testing 5 Sign-off Approval 1 Building a drug library is a team approach and is not entering drug records into the software provided by to be undertaken by one individual. Consider the pump vendor, and facilitates review meetings including the following key stakeholders: with stakeholders. Pharmacy Nursing drug library leader • Pharmacy admixing/compounding The nurse leader must have current clinical representative experience in infusion therapy and will serve as the • Clinical pharmacist representative for each lead nurse resource for the pharmacy drug library unique clinical care setting build. o Pediatrics/neonatology o Oncology Pharmacy admixing/compounding representative • Pharmacy & Therapeutics (P&T) committee This pharmacy team member provides expertise in representative how IV drugs are prepared, common formats for • Pharmacy representative for the EHR system each IV medication, typical container fill volume, (pharmacist informaticist) stability data, clinical care settings where Nursing medications are used, and label information affixed • Nurse educators to the container. This person is instrumental in • Nursing manager/representative for each clinical supporting the standardization of concentrations care area during the drug library build process (see section on • Nursing representative for EHR system (nursing Drug Concentration). informaticist) Prescriber Clinical pharmacist representative for each care area • Prescriber representative from a critical care unit This pharmacy team member provides information • Prescriber representative from a general on indications for drugs prescribed, common dosing medicine unit and dosing methods and references to dosing limits. IT resource He or she confirms consistency to formulary and • IT representative with knowledge of the policies and procedures. organization’s wireless infrastructure P & T Committee pharmacy representative The Team This individual serves as a liaison for the drug library Pharmacy drug library leader development team, provides progress updates to The leader for the drug library build should be a the P&T Committee and ensures consistency pharmacist with in-depth knowledge of the between infusion practice and drug library setup. organization’s drug formulary and intravenous Pharmacy representative for EHR system infusion policies and procedures. The pharmacy leader must have readily accessible current drug This individual provides knowledge of the reference materials and an understanding of organization’s formulary, preset drug admixtures pharmacy admixing practices and procurement. The and commercially available premixed IV products, leader should also be familiar with using Microsoft and knowledge of prebuilt order sets within the EHR Windows software. This individual leads the system. This person supports consistency between development of the drug library, is responsible for the organization’s formulary and the infusion system drug library and ensures all drug entries are 2 consistent with order sets in the EHR. Additionally, IT representative this individual is responsible for mapping This member provides expertise on the IT (associating) all IV medications from the EHR to the infrastructure to support the secure connection of infusion system drug library and ensures alignment the infusion pumps to the hospital wireless network, with systems such as automated dispensing cabinets as well as ensures the appropriate server and IV workflow management system. architecture is in place for wireless distribution of the drug library to the infusion pumps. In addition, Nurse educator this person will support the technical aspects of This critical member provides expertise in current Bedside Barcode Medication Administration (BCMA) infusion delivery practices and ensures that all for integration of the infusion pump into the EHR. affected policies and procedures are updated. This individual is responsible for organizing hands-on Step TWO – Formalize the Process education for nurses, anesthesia providers, and pharmacists during the implementation of the new It is important to establish formal processes for infusion system. approving the drug library as well as managing change requests (CR) and new requests (NR) for any Nurse managers/representative for each clinical care drug library revisions, both for the EHR system and area the infusion system drug library. Changes to one These members provide insight into current infusion system need to be aligned to ensure consistency and practices and are directly involved with the drug patient safety. This will ensure a robust history file library build in providing input and participating in and audit trail for all edits to the drug library. drug library reviews. Step THREE – Defining the Scope Nurse representative for EHR system Identify all medications that will be delivered using This individual provides expertise for nursing the infusion system. Consider taking a broad workflow between the EHR system and infusion approach first and then reviewing specifically for system programming and ensures that all clinical each drug or classes of drug and care area setting scenarios related to drug orders and other related (see Figure 2). interaction with the EHR system are considered. This individual provides detailed understanding of All medications and fluids should be delivered using required clinical documentation in the EHR for a smart infusion system whenever possible. infusions delivered using an infusion pump. Your assessment may be based on the following: Prescribers Drug format / container Prescribers provide insight into prescribing practices • Chemical and physical properties such as intended therapy, route of administration, • Fill volume and container type and size drug and concentration selection and dosing • Intended therapy and patient population methods. They are critical in supporting • Other ancillaries required for administration standardization of concentrations during the drug library build process in addition to standardization of order sets within the EHR system. 3 Delivery of infusion External environment • Route of administration • Identify clinical care area settings where this • Dosing units drug is intended to be infused • Dosing method Figure 2 offers some examples to consider when • Flow rate and accuracy requirements evaluating drugs to be used with the infusion pump • Continuity of flow requirements system. • Drug compatibility with approved pump administration sets In addition, each drug must be reviewed for how it is currently being infused, the safety and effectiveness of the current infusion method and the potential Figure 2 Defining the scope impact of any changes to the current delivery method. Identify drug to be assessed Step FOUR – Collecting Relevant Does it meet pump criteria for: o Fill volume, container type and size Information o Intended therapy and patient NO population o Other ancillaries required Gather the necessary information to initiate a drug library build that is consistent with current practice Out of Scope YES and hospital policies and procedures. The following are suggestions of data to collect: Does it meet pump criteria for: o Route of administration NO o Dosing units o Flow rate and accuracy Medication ordering/administration • Standard order sets for each medication and/or Out of Scope YES therapy • EHR interoperability workflow; auto- Does it meet pump criteria for: programming initial dose and dose changes o Dosing method o Continuous o Intermittent NO • List of IV medications admixed by nursing and o Loading/bolus o Multi-rate admixing chart used by nursing • Medications administered