Originally published by our sister publication Pharmacy Practice News
Mayo Clinic recently standardized large-volume infusion pump drug libraries throughout its U.S. enterprise, resulting in what the project leaders believe are optimized clinical practice workflows and an improved drug library management process. Other health enterprises such as University of Utah Health, in Salt Lake City, and St. Jude Children’s Research Hospital, in Memphis, Tenn., also have completed pump library standardization projects, which require heavy lifts at first but can lead to fewer drug dosage errors from smart pumps.
Prior to the standardization project at Mayo Clinic, a centralized pharmacy informatics team had already begun to oversee regional drug libraries. However, variances in practice remained in regional libraries related to dose error reduction systems (DERS), infusion settings and care areas (Am J Health Syst Pharm 2023 Aug 1. doi:10.1093/ajhp/zxad172).
Differences in regional drug libraries also existed partly due to legacy electronic health records (EHRs) and different pump operating system software. After Mayo Clinic leaders decided to adopt the Epic Systems EHR throughout the system, clinical informaticists first standardized the EHR system for the entire organization. Subsequently, the Drug Library Committee began standardizing drug libraries for Mayo Clinic’s smart pumps.
“To ensure that patients [at all Mayo Clinic facilities] receive the same standard of care with respect to intravenous medications, we decided that this was a project that we need to … start working on,” said Samuel Ubanyionwu, PharmD, RPh, BCPS, a medication management informaticist at Mayo Clinic in Rochester, Minn., who led the project.
Smart infusion pumps are designed to minimize errors in dispensing IV medications. Even so, a 2017 multicenter study showed that almost 9% of IV medications administered with smart pumps had some kind of error due to an infusion programmed without the oversight of the standard error alert system (BMJ Qual Saf 2017;26[2]:131-140). Smart infusion pump guidelines from the Institute for Safe Medication Practices advise hospitals to maintain a 95% or greater DERS compliance rate for infusions administered, a standard that Dr. Ubanyionwu and colleagues sought to meet or exceed.
“Throughout the regions, there were variances identified with drug library configurations, and each region had their rationale for doing so. Part of our job was to consolidate these differences into best-practice recommendations for the entire enterprise,” Dr. Ubanyionwu added. Before these best practices were implemented throughout Mayo Clinic, multiple oversight committees approved the infusion pump updates that Dr. Ubanyionwu’s team developed. These recommendations came about after extensive consultation with subject matter experts and enterprise specialty approving bodies.
“We did the tough work on the back end,” Dr. Ubanyionwu said, ultimately resulting in approval of the newly standardized and converged infusion pump drug libraries.
These new libraries were deployed throughout Mayo Clinic on a single day in April 2022, coinciding with a quarterly EHR update. After the libraries became available, seven of the eight regions saw an improvement in DERS compliance for infusions administered with the standardized and converged drug library. Dr. Ubanyionwu and colleagues calculated the DERS compliance rate using the Baxter Care Everywhere Gateway infusion management system.
One Mayo Clinic region’s DERS compliance rate went from 94.2% in the 30 days before the program began to 98.2% (P<0.001) in the 30 days after it started. Another region moved from 95.1% compliance to 99.4% compliance (P<0.001). Even regions that did not reach the 95% DERS compliance threshold saw improvement. For example, one region moved from 89.2% to 91.7% compliance (P<0.001) after the project.
University of Utah’s Approach
Pharmacists and informaticists at University of Utah Health have integrated standardized infusion pump libraries settings and drug concentration settings into their EHR (Am J Health Syst Pharm 2023;80[suppl 3]:S119-S122). The goal for standardizing infusion resources, the investigators wrote, is to reduce confusion as well as improve pharmacy operations, nursing workflow and patient safety.
“Ensuring interoperability between these different data sources can streamline workflow and reduce errors because all actions are logged and conducted within clinically safe parameters,” said Kristen Hughes, PharmD, BCPS, a clinical pharmacist at St. Jude Children’s Research Hospital, who was not involved in the project. “This can be hard to do if a health system has different infusion pumps with distinct specifications throughout its facilities.
“There are financial barriers to switching out your pump fleet” so that every facility in a system has the standard equipment, but you can also gain economies of scale if an organization decides to take this on to encourage consistent patient care, Dr. Hughes noted. She advised consulting with infusion nurses or other specialties commonly using infusion pumps, as well as pharmacists to make the selection of one systemwide solution.
“Nurses and other specialties infusing medications are on the front lines using the pumps, and their expertise is invaluable to this decision,” Dr. Hughes said.
One way for health systems to standardize infusion data sources is to ensure that drug orders entered in the EHR are consistently built in matching units or can be converted to those configured in the pump library itself. “Without matching the units being sent from the EHR, orders wouldn’t be useful to the infusion software, and thus would never make it to the pump,” Dr. Hughes said.
Another important element is collaboration between those building pump libraries and those cataloging drugs in the EHR. St. Jude created a process to ensure new drugs entered within the EHR that also needed to be built within the infusion pumps were identified “and sent to our team as a task as part of our medication build process to build into the pump,” said Madison Cole, PharmD, BCPS, a clinical pharmacist at St. Jude. Given that St. Jude’s clinicians see patients ranging from neonates to adults, choosing standard drug concentrations can present challenges when the appropriate concentration for one of the age extremes has not already been built.
As an immediate solution, a clinician may request a different drug concentration to be built within the EHR, but in some cases end users may be required to bypass the safety features (i.e., dose error reduction software limits) of the pump and infuse in a “basic mode” offered by the pump vendor. Examples like this highlight the need for a standardized approach for choosing standard concentrations.
“What we want to do … is make sure our pumps have drug concentrations that are amenable to all our patient populations,” Dr. Cole said. Dr. Hughes suggested that the best way to do this is to have clinicians who serve all patient populations at the table as early as possible, so that the resulting pump libraries have maximum flexibility.
The sources reported no relevant financial disclosures beyond their stated employment.