TJC, ISMP tips for smart pump safety

Although “smart” programmable IV pumps have become commonplace across hospitals and health systems, simply having the technology in place does not necessarily mean the brains of the device—namely, dose error reduction software (DERS)—are being used.

“There is room for improvement in monitoring of DERS use and in addressing the causes of non-utilization,” said Robert Campbell, PharmD, the clinical director of the Standards Interpretation Group and director of Medication Management, the Joint Commission, in Oakbrook Terrace, Ill.

To help organizations increase use of DERS by staff, the Joint Commission recently issued a Sentinel Event Alert (bit.ly/3G2g1ic) providing a slew of recommendations for organizations to consider for reducing the likelihood of users programming an infusion in basic mode or bypassing safety features (sidebar). In 2020, the Institute for Safe Medication Practices (ISMP) published its own guidelines nudging institutions to make greater use of built-in DERS for nearly every type of infusion in all settings (bit.ly/3lW4c5e).

Leading hospitals around the country have demonstrated that measures such as those laid out by the two patient safety organizations are effective. Stacy Carson, PharmD, a medication safety officer and co-chair of the smart pump oversight committee at AdventHealth, in Altamonte Springs, Fla., helps manage a fleet of smart pumps (Plum 360, ICU Medical and Medfusion 4000 and CADD-Solis, Smiths Medical) at eight AdventHealth facilities in the Orlando area. One initiative that she and her colleagues rolled out in 2018 led to a 23% increase in DERS compliance.

Dr. Carson said effort included partnering with the pump vendor to perform walkrounds, improving general staff knowledge of the library, relaunching the smart pump oversight committee and updating the library with improvements.

“One simple improvement we made at the time that had a big effect on library compliance was moving the ‘no drug selected’ option in each library profile entry from the top of the list of options down to its alphabetical location,” Dr. Carson said. “Although there are times when it’s necessary to manually program an infusion outside of the drug library, changing the location of this option made it easier to do what’s right and harder to do what’s wrong.”

After implementing the initiative, the organization saw DERS compliance increase from 70.2% to 94.1% over a twomonth period, Dr. Carson said.

At Vanderbilt University Medical Center, in Nashville, Tenn., where Terry Bosen, PharmD, is the medication safety program director, smart pump optimization efforts are part of everyday practice. For example, nurse leaders check infusion pumps during rounds, Dr. Bosen said. “If they see that an infusion has been programmed in basic mode, they switch it to the library entry.”

To further optimize their smart pump usage, she and her colleagues periodically analyze the trove of data on alerts, alarms, overrides and other potentially valuable metrics generated by smart pumps—a strategy that the Joint Commission recommends to enhance pump safety.

“Based on our alert data evaluation, we decide whether to change dose and infusion alert limits to reduce nuisance alerts and decrease programming alert fatigue,” Dr. Bosen said.

Until recently, she and her colleagues also were part of the REMEDI network, a collaborative of health care organizations that shared their experiences employing smart infusion pumps. “Being able to see other institutions’ drug entry builds was particularly helpful for those entries that are more complicated to create, and comparing drug entry limits helped us evaluate our standards of practice.

“We’re all doing the same quality improvement work and are very busy, which makes collaborating so important and effective,” Dr. Bosen added, lamenting that REMEDI is being shuttered as of November 2021.

Emily Grant, RN, a patient safety coordinator at UCHealth University of Colorado Hospital (UCH), in Aurora, said her organization has made smart pump optimization a priority by building a multidisciplinary group to oversee its use of these devices—another recommendation outlined in the Joint Commission’s Sentinel Event Alert. The team includes representatives of departments ranging from pharmacy to nursing, clinical engineering and informatics, information technology, and electronic health record (EHR) analytics, among others.

“This team sees the big picture while also identifying subtle gaps that, when aligned, could allow an error to reach the patient,” Ms. Grant said.

As the Joint Commission recommends, the team regularly reviews the smart pump drug library (they use Alaris pumps), including new formulary additions, top alerting drugs and guardrail alerts. This process is an opportunity to ensure all library entries are current, they support clinical practice for a diverse patient population, and that parameter limits are appropriate and do not lead to alert fatigue, Ms. Grant said.

Unlike most organizations across the country (ASHP sidebar), UCH has integrated smart pumps with its EHR (Epic). The move “was a game changer,

• Create a multidisciplinary project team or department to assume responsibility for smart infusion pump interoperability, including dose error reduction software (DERS), the oversight of drug library revisions or additions, infusion protocols, smart infusion pump maintenance, and related issues. • Define a process to create, test, regularly engage with, and maintain a drug library, including standardizing parameters, creating subsets and limiting availability of custom concentrations. • Train and assess competency of all clinical staff who use smart pumps. • Make the optimal use of DERS expected practice. • Monitor alerts, overrides, equipment or software recalls and adverse event and close-call reports. • If your organization has the capability, connect your smart pump fleet to your electronic health record system to enable autoprogramming. • Identify and address human and environmental factors that contribute to programming errors. These can include understaffing, workflow distractions and low lighting or glare. • Keep the smart pump fleet safe from security threats and during downtime.

Source: The Jont Commission (bit.ly/3G2g1ic)

providing the obvious benefit of automatic DERS compliance and allowing us to truly reap the rewards of autoprogramming by protecting patients from the majority of wrong dose, weight, duration, rate and concentration errors,” Ms. Grant said.

Since linking their smart pumps to their EHR in 2015, Ms. Grant and her colleagues shifted from looking at DERS compliance to focusing on compliance with EHR–pump autoprogramming. Reducing the chance that an end user will have to manually program after an infusion is autoprogrammed has required paying close attention to how orders are built in the EHR, Ms. Grant said.

For example, she noted, EHR “builds” should accommodate workflow considerations such as overfill in a bag and any additional volume added in the priming process. “If you don’t take that into account, users will have to manually adjust the volume to be infused after it is sent to the pump.”

Ms. Grant said she and her team encourage use of interoperability by explaining the patient safety benefits of the practice. They also have made it a point of ensuring a reliable wireless network is in place wherever smart pumps are being used with interoperability functionality because users “lose faith in the system and start seeking workarounds” when connectivity is spotty, she said.

“One of our newer hospitals opened up some shelled space during the pandemic and had dismal integration compliance,” Ms. Grant added. “After reviewing the data, we quickly saw that a weak wireless network was the culprit.”

Nurses have played a central role in smart pump quality improvement initiatives at UCH, Ms. Grant noted, explaining that they can shed light on whether smart pump alerts are triggered because a drug library entry does not support clinical practice or whether “there is an opportunity to reeducate staff on recommended workflow.”

Nurses also are encouraged to report pump issues and errors using a convenient streamlined incident report process initiated directly in the EHR. “We have incentives for reporting, such as a point-based recognition program with redeemable awards, and we celebrate those whose reports result in fixes and safety initiatives,” Ms. Grant added.

The combination of nurse reporting and leadership-driven change has led to impressive integration compliance. “At one of our main hospitals, compliance increased from 92% in 2019 to 92.5% in 2020, and thus far in 2021, it is averaging 92.7%,” she noted, saying “even small increases in compliance during a pandemic are laudable.”

Michelle Mandrack, MSN, RN, the director of consulting services at ISMP, emphasized that although integrating smart pumps and EHRs is “the new horizon” for smart pumps “and eliminates a big chunk of opportunities for programming errors, getting that EHR integration in place is a lengthy and costly interdisciplinary effort, and not necessarily within everyone’s reach at the moment.” She added that the ISMP and Joint Commission smart pump practice recommendations are a good place to start making full use of the safety features offered by the infusion devices. “We’ve had smart pumps for 20-plus years, and many institutions are not maximizing what this technology can do for us on its own.”

• 262 hospitals surveyed in 2020. • 87.9% reported using smart infusion pumps, up from 32.2% in 2005. • Use of smart infusion pumps varied by hospital size, with 79.6% of hospitals with 50 or fewer beds using the technology, compared with 100% of hospitals with 600 or more beds. • 13.4% said they had a smart pump–EHR interface that autoprograms pumps with information from the EHR, up from 8.9% in 2017. • 14.9% of respondents said they have an EHR–pump interface allowing smart pumps to autopopulate infusion data to the EHR. • The remaining 85.1% of hospitals require nurses to manually document infusion data in the EHR.

Source: Am J Health Syst Pharm 2021;78(12):1074-1093.

—David Wild

Dr. Carson reported fi nancial relationships with ICU Medical and Smiths Medical. The remaining sources reported no relevant fi nancial disclosures.

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