By Geri Aston

Marianne Fields, R.N., director of medical surgical services (left) and Carolyn Williams, pharmacist and medication-safety specialist, St. Joseph’s/Candler, Savannah, Ga., use education and training to ensure proper use of smart pumps.

Nine months after St. Joseph’s/ Candler switched to “smart” infusion pumps in 2002, the first analysis of the data stored in the devices uncovered an interesting pattern. The sedative propofol clearly was responsible for a large number of alerts signaling that nurses were initially programming doses outside the range set in the pumps’ drug library. The Savannah, Ga., hospital system launched a continuous quality improvement (CQI) project to discover what was going on, says Carolyn Williams, a pharmacist and medication safety specialist. Dosing propofol is difficult because it’s used on ventilated patients and the range of dose to achieve adequate sedation is significant, she explains.

The CQI analysis went a step beyond propofol, Williams says. “We broadened [the project] to say, ‘Are we using pain meds appropriately in these sedated patients? Are we using other medications that would assist with this appropriately?’”

The result of the effort was an overhaul of physicians’ propofol orders, infusion programming and documentation of the drug’s administration, along with staff education, Williams says. The new order set includes a standardized initial dose and then, depending on how the patient responds, allows the amount to be increased or decreased. Patients also are assessed to determine if they need pain medication.

The changes improved patient outcomes, says Marianne Fields, R.N., director of medical-surgical services. “We felt like patients got off the ventilator sooner, and that we really influenced reduction or avoidance of ventilator-associated pneumonia.” Fields and Williams are “absolutely sold” on the value of the data stored in smart pumps as a quality improvement tool. They’re not alone. Surveys show that between 44 percent and 64 percent of hospitals have smart pumps.

For the last several years, almost all infusion pump sales have been smart pumps, says Erin Sparnon, senior project engineer in ECRI Institute’s Health Devices Group. Of the hospitals using the devices, nearly 47 percent analyze the information stored in the pump logs for quality improvement, according to a survey by the American Society of Health-System Pharmacists (ASHP) conducted in late 2007. Over the past five years, the data has become much easier to access and use with the development of pumps with wireless capabilities. Nearly 30 percent of hospitals have pumps that automatically download data into a server wirelessly, the ASHP survey found. That percentage is expected to increase steadily as devices without wireless connectivity hit their shelf lives and hospitals replace them, says Eric Melanson, director of marketing for infusion systems at B. Braun Medical Inc.

Hospitals that have pumps without wireless capabilities typically analyze the data stored in them once a year or so, notes Jesse Guerra, R.N., Cardinal Health market manager, Alaris Products. That’s because it takes so much time to go to each machine to download the data. The information stored in the machines includes when nurses used the pumps’ drug library and when they didn’t, when alerts sounded because a nurse programmed the device outside the hard or soft dose limits set in the library and when nurses overrode a soft alert. The data is so rich that it’s cumbersome to mine without a wireless system, Guerra says.

When hospitals switch to wireless pumps, the initial findings are “almost always eye-opening,” Melanson says. “I very much analogize this to a data flight recorder in an aircraft. Hospitals really haven’t seen their IV therapy practices in quite this much detail because the data was not readily available. The [software] has this capability of really unlocking a lot of information about how therapy is conducted in the hospital.”

Hospitals have found multiple quality-improvement uses for the information, including tracking and analyzing dosing alerts, checking nurses’ use of the drug libraries, and discovering supply and workflow issues. With wireless smart pumps, hospital quality officials can go through the data every couple of days, weekly or monthly for CQI purposes, say device company officials.

Wireless interests

About a year and a half after going wireless, Clarian Health is developing a plan for its data. The Indianapolis hospital system has had smart pumps since 2002, but only examined the data when a situation arose. But last summer, the system began looking at drugs that generated a lot of alerts and issued a report to several departments and committees.

“Our primary goal was to look for the good catches we were making to advertise how great the technology is and how well it’s working,” says Brandi Hartnagel, medication safety coordinator. Clarian Health plans to use the pump information more for quality assurance this year, she says.

Other institutions are farther along in their efforts. Northwestern Memorial Hospital in Chicago switched to wireless smart pumps in 2007. The staff looks mainly at the percentage of doses administered with the pumps’ safety system on and at the number of dosing alerts, says Cindy Barnard, director of quality strategies. Analyses are conducted monthly and reported to the medication safety committee at least quarterly. Smart pumps allow the user to program the machine outside the drug library limits, Barnard notes. This feature is necessary because some patients and some circumstances call for dosing outside the norms. At Northwestern, compliance—use of the drug library—is 90 percent or better, Barnard says.

“So, that tells you that your library is reasonable, that people are finding it helpful, that they want to work within the safety systems that you’ve established.” The staff also looks for patterns in dosing alerts to make sure the drug library is set up correctly, Barnard says. If a medication is generating too many alerts, it means the dosing limits might need changing to better meet clinical needs. Failure to modify drug libraries when medication protocols change or new uses are found for old drugs can result in too many dosing alarms, and that can cause “alert fatigue” among nurses.

“Those libraries need to be updated on a regular basis. If it’s outdated and not matching the orders, it would delay giving the medication, so [nurses] just bypass the drug library and go to basic infusion,” explains Cora Vizcarra, R.N., president of the Infusion Nurses Society.

The trick is to make sure the library’s limits aren’t too loose, but aren’t so tight that nurses have to override them frequently for care that is clinically appropriate, says Carol Thompson, professor of critical and acute care nursing at the University of Texas Health Science Center and member of the Society of Critical Care Medicine’s Council.

Hospitals typically don’t use pump data to track which individual nurses have gone outside the pump safety system. Doing so would require a bedside medication bar-coding system that prompts nurses to input their ID numbers, ECRI’s Sparnon says, and the ID-input concept is unpopular. Most hospitals rely on visual checks of the pumps on the floors and on nurses  to self-report errors.

Data can be used as a learning tool for nurses, Fields says. In some cases, an unusual dose can be tied to a specific patient and the supervisor can figure out which nurse was caring for the patient at the time. “There is always learning that comes out of it,” she says. “The majority of the time, everything was done appropriately and her thinking was correct.”

Pattern assessment

Another use of the pump data is to look for patterns in alerts to identify if drug protocols need changing or nurses need some education. At St. Joseph’s/Candler, Williams looks at the logs every couple of weeks. In one case, the data showed more alerts than expected with the anticoagulant heparin. It turned out nurses were sometimes programming continuous infusion at the higher initial dose. The smart pump alarms alerted nurses to the error and allowed them to correct the dose before infusion, Williams says. 

“The pharmacy now works collaboratively with nurses to evaluate the lab’s determination of how to adjust the dose,” Fields says. “That, along with changing the protocol so that the wording is more clear, helped tremendously.”

The data logs (often for the first time) give the pharmacy staff a clear picture of what is happening on the floors, pump manufacturer representatives say. Clinician practice is not always what the pharmacy assumes, says B. Braun’s Melanson. “Sometimes the level of meds that could be given for that patient may not look like the textbook level of range that the pharmacy department thinks it should be because the real patient experience and the real practice on the floor is different from what the textbook says.”

Smart pump data also can point out the need for changes that aren’t clinical. One of the main uses is for “pharmacy economics,” Melanson says. For example, a pharmacy as a standard practice sends 250-milliliter bags of fluid to the floors, but when the pump information is examined, it shows that most patients are only prescribed 100 to 150 milliliters. The data reveals an opportunity for the pharmacy to save money by making less solution.

The information can uncover the need for workflow change. Sparnon gives the example of a children’s hospital that ran a data analysis looking at pump alerts by time of day. The report revealed a spike in alarms in one care area at about 6 p.m. A look at what was happening in the unit found that this was the 11th hour of a 12-hour shift and that there was a daily medication round at that time.

Also, 6 p.m. is when parents coming home from work often bring in sick children. So the facility moved the medication round to an earlier time, and the alerts went down significantly because clinicians weren’t as harried, Sparnon says. “They were able to provide better, safer care.”

To a large extent, what hospitals get out of the pump technology depends on the vendor and its software, Sparnon says. “There’s myriad ways to slice and dice the information,” she says, and some suppliers are better than others about offering standard reports that include the CQI data of most interest to hospitals.

It’s also beneficial for the software to let hospital staff automatically set up regular reports that, for example, detail for all the nursing managers what happened in their care areas each month, Sparnon says. “That reduces the burden and gets the information out to the people who need it.” Many hospitals are making good use of the data, but it takes an investment of time and money, she says. Some facilities have a full-time person whose job is to cull all the pump information and present it to the right people; some vendors provide that as a consulting service.

One example is Cardinal Health’s Performance Analytics Service, under which the wireless smart pump data is securely transmitted to the company. There, medication safety experts analyze it and send it back to the hospital each month with suggestions of areas on which to focus.

Device-makers constantly are learning from their hospital clients and improving their software, say Cardinal Health and B. Braun representatives. More than 200 hospitals share their data sets with Cardinal Health. The collaborative relationship has resulted in such advances as pump safety limits for how fast a medication can be given, Guerra says.

Many suppliers have been responsive to hospitals because it gives them a competitive advantage, Sparnon says. The drug libraries, when coupled with a good log and log analysis software, give both hospitals and the smart pump manufacturers an eagle’s eye view of what’s going on at the bedside, she adds.

Geri Aston is a freelance writer based in Chicago.

This article first appeared in the April 2009 issue of Materials Management in Health Care.

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